Professional Documents
Culture Documents
To my husband Alan and my children Daniel and Matthew. My life would not be complete without you!
Irina Szmelskyj
Also in the loving memory of my baby nephew Georgio Aquilina, and Indie.
Lianne Aquilina
For Elsevier
Content Strategists: Claire Wilson, Alison Taylor
Content Development Specialist: Sally Davies
Project Manager: Sukanthi Sukumar
Designer: Christian Bilbow
Illustration Manager: Richard Tibbitts
Illustrator: Antbits Ltd.
Acupuncture for IVF and
Assisted Reproduction
An Integrated Approach to
Treatment and Management
Irina Szmelskyj DipAc MSc MBAcC
Lead Clinician, True Health Clinics and Founder of The Fertility Foundation, Godmanchester, Huntingdon;
Module Leader, Lecturer and MSc Supervisor, Northern College of Acupuncture, York; Guest Lecturer,
University of Lincoln, Lincoln, UK
Edited by
Alan O. Szmelskyj DO MSc AdvDipClinHyp FRSPH
Senior Clinician, True Health Clinics, Godmanchester, Huntingdon; Scientific Advisor, The Stress
Management Foundation, Godmanchester, Huntingdon, UK
Foreword by
Giovanni Maciocia CAc (Nanjing)
Acupuncturist and Medical Herbalist
Visiting Professor, Nanjing University of Traditional Chinese Medicine, Nanjing, People’s Republic of China
Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto 2015
To my husband Alan and my children Daniel and Matthew. My life would not be complete without you!
Irina Szmelskyj
Also in the loving memory of my baby nephew Georgio Aquilina, and Indie.
Lianne Aquilina
For Elsevier
Content Strategists: Claire Wilson, Alison Taylor
Content Development Specialist: Sally Davies
Project Manager: Sukanthi Sukumar
Designer: Christian Bilbow
Illustration Manager: Richard Tibbitts
Illustrator: Antbits Ltd.
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Biographies
IRINA SZMELSKYJ
Irina Szmelskyj is the co-director and lead clinician of True Health Clinics and is the founder of The
Fertility Foundation.
With more than a decade of experience specializing in reproductive healthcare, including the
healthcare needs of patients with infertility issues and the use of acupuncture in the clinical manage-
ment of patients undergoing assisted reproductive treatments such as In Vitro Fertilization (IVF),
Irina’s method of managing subfertile patients is based on a thorough understanding of the value
of combining the best of Traditional Chinese Medicine (TCM) and conventional medicine.
Her unique approach emphasizes the clinical utility of integrating both classically based traditional
acupuncture treatment techniques and concepts with the practical clinical application of contempo-
rary evidence-based advances, from the rapidly changing landscape of reproductive medicine research.
In addition to her clinical experience, Irina holds several academic posts at the Northern College of
Acupuncture in York, including Module Leader for the MSc in Advanced Oriental Medicine and MSc
in Advanced Complementary Medicine courses, as well as supervising Masters level acupuncture
students. She also lectures undergraduate university students on the use of acupuncture treatment
in the management of infertility and during IVF.
In 2006 she was the recipient of the British Acupuncture Council’s nationally recognized Annual
Research Excellence Award. She is a member of the Acupuncture Fertility Network (AFN), the
National Network of Zita West Affiliated Fertility Acupuncturists, the British Fertility Society, the
American Society for Reproductive Medicine (ASRM), and the European Society of Human Reproduc-
tion and Embryology (ESHRE).
LIANNE AQUILINA
Lianne Aquilina is from a family of nursing specialists and started her early career as a qualified dental
nurse specializing in anxiety management and reduction – a skill that has proven invaluable in her
fertility work. She went on to study complementary medicine with the specialization of Traditional
Chinese Medical Acupuncture. In 2005 the Faculty of Health, Life and Social Sciences of the Univer-
sity of Lincoln awarded her the Dean’s prize for Studies in Health. In 2008 Lianne was invited to join
the University of Lincoln’s teaching team as an acupuncture clinical supervisor.
Lianne was part of the first group of Traditional Chinese medical practitioners from England to
complete further clinical training at the Guangdong Province Second Hospital of Traditional Chinese
Medicine (TCM) in China. It was here that she observed the authentic combination of Traditional
Chinese and orthodox medical strategies in treatment and management; she developed these insights
for her patients undergoing In Vitro Fertilization (IVF) and other methods of Assisted Reproductive
Medicine (ART).
ix
Biographies
Lianne’s interests led to further study of Chinese medical classics as part of a Master of Arts pro-
gramme, where she obtained a distinction from the College of Traditional Acupuncture, Warwick,
UK, affiliated with Oxford Brookes University (2009).
Lianne Aquilina specializes in applied classical Chinese philosophy as the basis of Traditional
Chinese Medicine reproductive health. She is an advocate of the importance of developing the thera-
peutic relationship and integrating acupuncture into mainstream medicine in response to the con-
temporary healthcare needs of subfertile patients.
Lianne’s research project as part of her degree was published in order to demonstrate various
approaches to qualitative research in healthcare.
For several years Lianne and Irina have teamed up to lecture undergraduate students on the use
of Traditional Chinese Medicine and acupuncture treatment and the management of subfertility
and IVF.
In 2012, Lianne was asked to join the British Acupuncture Accreditation Board (BAAB) as its accred-
itation observer for the accreditation of an MSc acupuncture course. Lianne is a member of the Asso-
ciation of Traditional Chinese Medicine (ATCM) and the British Acupuncture Council (MBAcC). She
is an Associate Forum Member of Classical Chinese Medicine, an Associate member of the Ayurvedic
Practitioners Association (APA), the American Society of Reproductive Medicine (ASRM), the British
Fertility Society (BFS) and an Academic Associate of the British Medical Society (BMAS). She is the
Founder, Director and Lead Clinician of Aquilia Acupuncture and Aquilia Fertility in Stamford,
Lincolnshire.
ALAN SZMELSKYJ
For several years Alan Szmelskyj was an editorial board member of the British Osteopathic Journal
before becoming chief editor of the peer-reviewed Journal of Osteopathic Education and Clinical Practice.
Alan has had articles and contributions published in several peer-reviewed medicine and health-
care journals including Complementary Medical Research, Complementary Therapies in Medicine, Holistic
Medicine, The Practitioner, Imaging and the BMJ amongst others.
Previous appointments include preventative medicine roles in the Occupational Health Depart-
ments of both Hinchingbrooke NHS Trust and Papworth NHS Trust. As well as a Senior Research
Fellowship, he has held lecturing roles at several osteopathic schools and lectured at international
postgraduate conferences.
As well as being an enthusiastic supporter of preventative healthcare at both the individual patient
level and in society in general, Alan has a longstanding interest in the role of bio-psychosocial aspects
of health and medical care and the mediating role that psychosocial stress may play as an effector
mechanism in the pathophysiology of ill health and disease morbidity.
Previously published work attests to Alan’s fascination for trying to develop both novel theoretical
hypotheses and clinical practical applications that can tap into some of the processes and techniques
involved in the enhancement of the therapeutic value of the relaxation response. He was awarded his
Masters degree in the Psychobiology of Stress at the University of Surrey and also completed an
Advanced Diploma in Clinical Hypnosis and Stress Management at Staffordshire University.
In addition to his primary professional organizational memberships, he is also a member of The
British Medical Acupuncture Society, the British Society of Clinical and Academic Hypnosis (BSCAH)
and a Fellow of the Royal Society for Public Health. Alan is also trained in the Fertile Body Method.
Alan is co-founder and lead clinician at True Health Clinics, Cambridgeshire, and founder of and
scientific advisor to The Stress Management Foundation.
x
Foreword
Like all branches of Chinese medicine, traditional gynaecology has a long history. The earliest records
of gynaecological medical writings date from the Shang dynasty (1600–100 BC): bones and tortoise
shells from that period have been found with inscriptions dealing with childbirth problems. The text
‘Book of Mountains and Seas’ from the Warring States period (476–221 BC) describes medicinal
plants to treat infertility.
The Nei Jing – Su Wen has many references to women’s physiology and anatomy, as well as the
diagnosis and treatment of gynaecological problems. It describes the function of the uterus and states
its connection to the Heart and Kidneys via the bao mai (Uterus Vessel) and bao luo (Uterus Channel)
respectively. For example, the ‘Simple Questions’ in Chapter 33 say: ‘In amenorrhoea, the Uterus Ves-
sel is shut. The Uterus Vessel pertains to the Heart and communicates with the Uterus; when Qi rebels
upwards to press towards the Lungs, Heart-Qi cannot flow downwards and amenorrhoea results’.1 In
Chapter 47 it states: ‘The Uterus Channel connects with the Kidneys; the Kidney channel reaches the
root of the tongue’.2
That gynaecology already existed as a speciality during the Warring States period is recorded in
the ‘Historical Annals’ (Shi Ji), which refer to the famous doctor Bian Que as one who ‘treats dis-
eases under the belt’ (Dai Xia Yi), that is, a gynaecologist. Although Bian Que is not a historical
figure, and the Shi Ji was compiled during the Han dynasty, it refers to events of the Warring
States period.
During the Han dynasty (206 BC–AD 220), a gynaecologist was called a ‘breast doctor’ (Ru Yi) or
‘women’s doctor’ (Nu Yi). The famous doctor Zhang Zhong Jing refers in his work ‘Discussion on
Cold-induced Diseases’ (Shang Han Lun) to a previous book entitled ‘Series of Herbs for Obstetrics’
(Tai Lu Yao Lu), which proves that even before the Han dynasty there were books dealing exclusively
with gynaecology, but all of these have been lost.
The ‘Discussion of Prescriptions of the Golden Chest’ (Jin Gui Yao Lue Fang Lun) by the same author
has three chapters on gynaecology: ‘On pregnancy’, ‘Post-partum diseases’ and ‘Women’s miscella-
neous diseases’. These chapters discuss disorders of menstruation, leucorrhoea, pregnancy, miscella-
neous diseases, and post-partum problems. These three chapters on gynaecology represent one of the
earliest gynaecological treatises, and they formed the model upon which subsequent books
were based.
The ‘Pulse Classic’ (Mai Jing, AD 280) by Wang Shu He, a famous doctor of the Jin dynasty (AD
265–420), describes pulse pictures and differentiation of women’s diseases in Volume 9. Wang
Shu He also added a wealth of comments from his personal experience in the gynaecological field.
For example, he says that ‘The Kidneys govern the Uterus, and its condition is reflected at the Chi
[Rear] position of the pulse. If the pulse at this region does not fade on pressure, it indicates preg-
nancy’.3 In another passage he says that ‘In pregnant women, a superficial pulse accompanied by
1
1979 The Yellow Emperor’s Classic of Internal Medicine-Simple Questions (Huang Ti Nei Jing Su Wen), People’s Health
Publishing House, Beijing, first published c. 100 BC, p. 197.
2
Ibid., p. 259.
3
Wang Shu He 1988 A Revised Explanation of the ‘Pulse Classic’ (Mai Jing Jiao Shi), with commentary by the Fuzhou City
People’s Hospital, People’s Health Publishing House, Beijing, p. 585. First published in AD 280.
xi
Foreword
abdominal pain referred to the midline of the lower back, indicates impending labour’.4 The book
also describes the qualities of the pulse before an imminent miscarriage, normal and abnormal pulses
during the post-partum stage and pulses in women with abdominal masses in relation to prognosis.
All subsequent classic texts contain a wealth of knowledge and clinical information on gynaeco-
logical and obstetric diseases. Especially of note are the ‘General Treatise on the Symptomatology
and Aetiology of Diseases’ (Zhu Bing Yuan Hou Zong Lun, AD 610) by Chao Yuan Fang and the ‘Thou-
sand Golden Ducat Prescriptions’ (Qian Jin Yao Fang, AD 652) written by Sun Si Miao. Sun Si Miao
made the interesting observation that a metal knife should never be used to cut the umbilical cord:
from a modern perspective, this was an important recommendation as, if dirty, a metal instrument
can easily provoke a tetanus infection.
The ‘Treasure of Obstetrics’ (Jing Xiao Chan Bao), written during the Tang dynasty, is the earliest
obstetrics book. The book contains twelve chapters on diseases of pregnancy, four chapters on dif-
ficult labour and twenty-five chapters on post-partum diseases. Diseases of pregnancy discussed
include morning sickness, bleeding, threatened miscarriage, miscarriage, urinary problems and
oedema. The discussion on labour problems includes formulae for promoting labour, dealing with
a dead foetus, prolonged labour and retention of the placenta. The discussion on post-partum dis-
eases includes tetanus, puerperal infections, abdominal pain, persistent bleeding, retention of urine,
lactation insufficiency and mastitis.
During the Song dynasty (960–1279) the imperial medical college was staffed by 300 people; there
were nine departments, one of which was obstetrics and gynaecology. This was probably the earliest
medical school department dedicated entirely to gynaecology and obstetrics. This led to the publica-
tion of many books specializing in obstetrics and gynaecology, an important one being the ‘Great
Treatise of Useful Prescriptions for Women’ (Fu Ren Liang Fang Da Quan, 1237) written by Chen
Zi Ming during the Southern Song dynasty. The book comprises 24 volumes, including 20 chapters
on menstrual diseases, 91 on miscellaneous diseases, 10 on infertility, 8 on ‘foetal education’, 9 on
pregnancy problems, 70 on post-partum diseases and 10 on boils and ulcers. More than 260 diseases
are discussed in all with various formulae for each. This book exerted a profound influence on the
development of obstetrics and gynaecology in subsequent dynasties.
During the Yuan dynasty (1279–1368) many different medical schools of thought flourished,
among which the main ones were those headed by Liu Wan Su, Li Dong Yuan, Zhu Dan Xi and Zhang
Zi He. Liu Wan Su (1120–1200) maintained that Fire is the primary cause of disease, and he therefore
advocated the use of cold herbs in gynaecological problems. For example, he attributed amenorrhoea
to Heart-Fire.
Li Dong Yuan (1180–1251) was the founder of the ’School of Stomach and Spleen’, which empha-
sized a disharmony between these two organs as the main aetiology and pathology of diseases. He
therefore advocated tonifying the Stomach and Spleen as the main method of treatment in gynaecol-
ogy, too. In his book ‘Secret Record of the Orchid Chamber’ (Lan Shi Mi Cang), he says that prolonged
deficiency of the Stomach and Spleen leads to amenorrhoea and that to treat this, one needs to clear
Stomach-Heat, generate Stomach fluids and tonify Qi and Blood. He says that uterine bleeding is due
to deficiency of the Stomach and Spleen, arousing Ministerial Fire of the Kidneys and causing Damp-
Heat to infuse downwards: To treat this, he advocates tonifying the Stomach and Spleen and
raising Qi.
Zhu Dan Xi (1281–1358) maintained that ‘Yang is often in excess and Yin is often deficient’ and
therefore advocated nourishing Yin as one of the most important treatment principles. For example,
for problems before childbirth he advised clearing Heat and nourishing Blood. He also indicated
Huang Qin (Radix Scutellariae baicalensis) and Bai Zhu (Rhizoma Atractylodis macrocephalae) as two
important herbs to prevent miscarriage. To this day, these are two important herbs used to prevent
miscarriage.
The doctors of the Ming dynasty (1368–1644) consolidated and integrated the theories of these
four great schools of medical thought. Many important gynaecological books were written during
the Ming dynasty, such as ‘Standards of Diagnosis and Treatment of Women’s Diseases’ (Zheng
Zhi Zhun Sheng - Nu Ke, 1602) by Wang Ken Tang, ‘Summary of Gynaecology and Obstetrics’
4
Ibid., p. 588.
xii
Foreword
(Nu Ke She Yao, 1548) by Xue Ji and ‘Summary of Fertility’ (Guang Si Ji Yao) and ‘Women’s Secrets’
(Fu Ren Mi Ke) by Wan Quan.
Interestingly, Wang Ken Tang said that, in order to conceive, the man should clear his Heart and
control his sexual desire to nourish the Jing, while a woman should calm her Mind and settle Qi to
nourish Blood.
The ‘Complete Works of Jing Yue’ (Jing Yue Quan Shu, 1624), by Zhang Jing Yue, has an extensive
section on gynaecology and obstetrics that discusses the treatment of problems of pregnancy and
labour, leucorrhoea, breast diseases, fertility, abdominal masses and menstruation. Zhang Jing
Yue recommended paying particular attention to regulating menstruation in gynaecological diseases.
He said that the key to regulate menstruation is to nourish Blood by tonifying the Stomach and Spleen
and calming the chamber of Blood by tonifying the Kidneys. On the question of whether the Spleen
or the Kidneys was the more important organ, he decided in favour of the latter.
During the Qing dynasty (1644–1911) many gynaecological treatises were written. The most nota-
ble one is ‘Fu Qing Zhu’s Gynaecology’ (Fu Qing Zhu Nu Ke) by Fu Qing Zhu (1607–1684).
‘Fu Qing Zhu’s Gynaecology’ is unlike any other gynaecology book in so far as the author proposes
his own personal, and often unorthodox, ideas on the pathogenesis and treatment of gynaecological
diseases and his formulae are unlike any of those from previous gynaecological books. One of the
central theses of Fu Qing Zhu’s book is that the Kidneys are the most important organ for the men-
strual function as they are the origin of menstrual blood. According to him, menstrual blood is unlike
normal Blood: it is a precious fluid derived from the Kidney-Jing. I personally completely agree with
this view, and the importance of tonifying the Kidneys in gynaecological problems to me cannot be
overemphasized.
Since 1949 the combination of Western and Chinese medicine has been emphasized, and many
innovative treatments have been devised. For example, ectopic pregnancy is often treated with acu-
puncture and Chinese herbs without recourse to surgery; acupuncture is used in breech presentation
of the foetus; Chinese herbs are used in the treatment of myomas and cervical carcinoma, and so on.
Since the major colleges of Traditional Chinese Medicine were established in 1956, many modern
gynaecology textbooks have been published and the ancient ones reprinted.
Of particular interest is the theory of the four phases of the menstrual cycle introduced by Dr. Xia
Gui Cheng; this is a theory that cleverly integrates the Chinese view of Yin and Yang in the menstrual
cycle with the Western view of oestrogen and progesterone and the follicular and luteal phases.
The treatment of female infertility has always occupied a major place in Chinese gynaecology. From
a philosophical and social perspective, this could be attributed at least in part to the Confucian views
on family and society. Confucian philosophy had a huge influence on Chinese medicine, an influ-
ence that in my opinion is not recognized. Most practitioners think that Chinese medicine is Daoist
and that the Nei Jing is a Daoist text. In fact, the whole cultural background of the Nei Jing is
completely Confucian and partly Legalist. For example, the view of the Internal Organs as ‘ministers’
and the Heart as ‘ruler’ is completely Confucian (Chapter 8 of the Su Wen). The Daoists would never
make such a comparison because they disliked all political power and government structures. If we
read Chapter 80 of the Dao De Jing we can see the description of the ideal Daoist society: a very small
community where one hears cocks crow from a community next door, but the residents never feel the
need to go there. Chapters 18, 19 and 38 of the Dao De Jing are stinging attacks on Confucian phi-
losophy, even calling it the ‘great hypocrisy’.
We should also remember that the Nei Jing was edited three times by Imperial Committees during
the Song dynasty (960–1279), which saw the complete triumph of the Confucian ideology that
remained the only accepted state ideology down to present times. I would even argue that many char-
acteristics of the present regime are more Confucian than Marxist. Of course, that is not to say that
there are no Daoist influences on the Nei Jing; there are. The very word su in the title Su Wen reflects
the typical Daoist ideal of being ‘unadorned’ like raw silk, that is, ‘simple’. Daoists advocated simplic-
ity of lifestyle and shunning of political power.
Going back to women, fertility and children, Confucianists attached huge importance to children
as a perpetuation of one’s lineage and also as caretakers of the graves of their parents. Filial piety (xiao)
is a fundamental cornerstone of Confucian philosophy. I think this is at least a partial explanation of
the huge importance given to fertility in gynaecology books.
As we all know, Chinese medicine can be very effective in the treatment of infertility. However, with
our patients, we are faced with new challenges that ancient Chinese doctors did not have, and that is
xiii
Foreword
the integration of our Chinese treatment with the modern techniques of ART. What would the ancient
Chinese doctors think of freezing an embryo and keep it frozen for years?
Many questions arise when treating a patient who is undergoing or will soon undergo ART. Should
we treat them according to the patterns seen in infertility, or should we do something different? If we
do something different, how should we time it? All these questions and more are answered in depth
in this book. Indeed, its title probably does not do it justice as the book does not deal only with the
approach to a patient who is undergoing ART. It also gives an overview of the Chinese medicine view
of the reproductive system and the Chinese patterns in subfertility.
I am delighted to introduce this book, the most comprehensive text on the integration of Tradi-
tional Chinese Medicine with modern ART techniques, which was written by practitioners with a
great deal of experience and deep knowledge of the subject.
Giovanni Maciocia
Santa Barbara, 2014
xiv
Preface
Over the past decade or so, acupuncture treatment of patients undergoing Assisted Reproductive
Technology (ART) treatments has gained in popularity. With this increased demand for acupuncture
treatment, the role of fertility acupuncturists in the management of patients undergoing ART treat-
ments has expanded. In contemporary fertility acupuncture practice, patients expect their acupunc-
turists to have a thorough understanding of not only Traditional Chinese Medicine (TCM), but also
all Orthodox medical aspects that relate directly to the practice of fertility acupuncture. Patients expect
their acupuncturists not only to treat them, but also to advise them about diagnoses, tests and inves-
tigations, clinic suitability, different treatment protocols, and stages of treatment and generally sup-
port them on many levels.
With these increased expectations, acupuncture practitioners find themselves looking for addi-
tional resources of information to supplement their often very limited training in this field of med-
icine. However, there is still a significant gap in the available literature on how to treat this
patient group.
With this book, we aim to provide fertility acupuncturists with an ‘all-in-one’ resource on just about
everything they are likely to need to know when managing patients undergoing ART treatments such
as In Vitro Fertilization (IVF). This textbook is based on our combined 20 years of clinical experience,
our experience of lecturing in this field and (whenever possible) on up-to-date evidence-based litera-
ture. This book draws its ethos and inspiration both from the technical complexities of the fast-
moving and ever-developing field of conventional reproductive medicine and synthesizes this with
traditional acupuncture practical approaches. The latter are derived from our interpretation of the
classical acupuncture texts and supported with contemporary acupuncture research-based studies
(where these are available). It attempts to simplify complex information into easily accessible and
understandable material.
This book will take acupuncture students and practitioners, step by step, through every aspect of
contemporary fertility and ART acupuncture practice. We believe it will cover just about everything
that a novice or an experienced fertility acupuncturist is likely to need to know, including:
• Reproductive anatomy and physiology, both from Orthodox medical and TCM perspectives.
• Orthodox medical fertility tests and investigations, including information on how to interpret
the results, what other tests may be suitable for patients, and when to refer them. Detailed
reference ranges for the most commonly used tests are provided.
• The pathology and aetiology of TCM syndromes and their associated ART complications that are
commonly seen in subfertile patients.
• Detailed information on how to take a fertility medical history and how to diagnose TCM
syndromes. Case history templates are provided.
• Evidence-based information on how various lifestyle factors affect fertility and ART success rates.
Ready-made factsheets are appended for acupuncturists to give to their patients.
• Guidelines on how to regulate the menstrual cycle in preparation for IVF treatment.
• How common fertility-related conditions such as endometriosis, Polycystic Ovary Syndrome,
thyroid disease, and male factor infertility affect ART success rates and what can be done with
acupuncture and lifestyle modifications to help patients succeed.
xv
Preface
Irina Szmelskyj
Lianne Aquilina
Huntingdon and Stamford 2014
xvi
Acknowledgements
Writing this book has been a long and in many ways challenging journey. It would not have been
possible if not for the help and support of many people.
I would like to express my gratitude to Tom Williams, my MSc research module teacher, who
believed in me; to my original research supervisor, Hugh MacPherson, who helped to steer me in
the right direction; and to my research supervisor, Léonie Walker, for helping me achieve the highest
possible standard of research. Without your input this book would not exist.
I would like to acknowledge my Northern College of Acupuncture colleagues, whose passion for
research is an inspiration to me. I have learnt a lot from you and will carry on learning. A very special
thanks to Lara McClure for helping me access the research material. I am humbled that the world-
renowned acupuncture expert Giovanni Maciocia found the time in his busy schedule to review this
book and write such a positive foreword – thank you! This book would not have been possible if it
was not for help provided by Richard Blackwell, principal of the Northern College of Acupuncture.
Richard, I am forever indebted to you.
My thanks to world expert on folliculogenesis, Alain Gougeon, for taking time to help me with my
research on follicular development. This is a very important aspect of female reproductive physiology,
which I believe acupuncture can directly influence. Thank you Raj Mathur and Stephen Harbottle of
the Cambridge IVF, Amin Gorgy of the Fertility Academy and one other person who can not be named
here (but I hope you know who you are) for your help with sourcing some of the laboratory images
used in this book.
All my patients who agreed to be case studies for the book – thank you! Also all the patients I have
treated over the years – I have learnt from treating each and every one of you and now I am sharing
this knowledge with other acupuncturists.
Thank you to my colleagues at True Health Clinics for putting up with me while I was writing this
book!
I would like to say an especially big thank you to Lisa Morton for creating some of the illustrations
for this book. You are a very talented designer. Also the many night shifts of writing would have been
much grimmer if it was not for your late-night support. You made me laugh so much that I cried. I will
not miss the night shifts, but I will miss our laughs.
I am grateful for the support of all my wonderful friends, in particular Katarina and Oksana, who
helped me to get through some difficult times.
This section would not be complete without expressing my sincere thanks to our publisher and our
editors Claire Wilson, Sally Davies, Alison Taylor and our project manager, Sukanthi Sukumar. Thank
you for being so patient with us and for allowing us the many extensions to the deadline that we so
badly needed.
I would also like to acknowledge my co-author Lianne. Fate brought us together to work on this
demanding project at possibly the most unsuitable times of our lives, when we had to juggle very
young families and long hours of research and writing. Chinese medicine at times is not easy to
understand and our combined efforts to take original TCM writings and to synthesize them into
something more contemporary and appropriate for the nature of this book was quite challenging.
We got through it, albeit somewhat battered and bruised!
xvii
Acknowledgements
Finally, my biggest thanks go to my family. To my husband Alan for suggesting that we write this
book, for inspiring me and believing in me, for spending many hours painstakingly editing the manu-
script and making it so much better, for making the countless cups of coffee to see me through the wee
hours of the night, and for doing the household chores to give me the time to write.
To my mum Maria, my stepfather Peter, and to my brother Yura for always being there for me, even
though I had very little time for you while writing this book.
And finally to Daniel and Matthew, my two very much loved and treasured children. Thank you for
playing quietly while ‘mummy was writing’, for allowing me to have power naps while settling you and
for ensuring that I stayed on schedule by checking the progress on my wall chart. You are my biggest
inspiration. I hope that in turn this book will inspire you to achieve even greater things in your lives.
Irina Szmelskyj
I would like to acknowledge and thank all who have provided me with the opportunity to make this
book a possibility. My special thanks go to Irina Szmelskyj, my co-author. As qualified acupuncturists
with different backgrounds we each bring a range of different interests, skills, and experiences. Col-
laboration in the making and production of our book has been challenging, yet an invaluable per-
sonal and professional experience. I would also like to thank Alan Szmelskyj, our chief editor, for his
time, expertise and advice. Thank you to our development editor, Sally Davies, and to Sukanthi
Sukumar, our project manager, for their expertise and input in the making of our book. Thank
you to Linda Husband, for securing me a place on the acupuncture course, and to Chris Low and
Richard Bertschinger, my tutors, who willingly recommended a broad range of great Chinese med-
icine literature and shared their knowledge during my studies. Thanks also to Paul Franks and Martin
Dean, my clinical supervisors, a great inspiration now and during my university days. Thank you to
Venkat Kumarasamy for allowing us access to some of the difficult-to-obtain medical journal articles
and for your help and advice.
Thank you, Gary Hares, ’Boss’, for the position upon graduation as an acupuncturist in three of your
busy clinics. Josephine Clegg of Sleaford Natural Health Centre, thank you for sharing your practice
with me and for all your advice. You both gave me an opportunity and the start I needed (I am so grate-
ful). Special thanks go to Fanyi Meng for inviting me back to the University of Lincoln (in my mid-twen-
ties) to teach Chinese medicine and clinically supervise third-year acupuncture students. Working
amongst a team of experts and eager students over so many years, in a vibrant, challenging and inter-
active learning environment has been a fundamental component in the continual development of my
professional practice and fed my fascination of Chinese medical acupuncture. My experience of this is
reflected wholeheartedly in this book.
I would like to extend my heartfelt thanks to my parents, whose work ethic has given me the aspira-
tion to write. Both my mum, Karen Baza, and dad, Juzi Aquilina, have been ideal role models with
regard to education, dedication and enrichment of my life. Thank you also Mr and Mrs Saleem. Oliver
Aquilina-Ford, my gorgeous son, thank you for all that you teach me about life. Thank you, Aunty
Susan, for looking after me so well. Big thanks, to Kelly Marie Bateson and Joel, Lou Congreve, Venkat
and John Wheeler for their support when needed for aspects of this project. A special thanks, also, to
Corinne Alexander, my associate acupuncturist for managing Aquilia Acupuncture marvellously.
Thank you to all my patients who consented to their case histories being used as a teaching tool.
Thank you, Dawn, my first fertility and IVF patient of 2003, for stimulating my interest in and passion
for fertility acupuncture.
I would like to thank those who helped me during my research for the TCM chapters and sections of
this book. I am extremely grateful to: Elisabeth Rochat de la Vallée for her guidance and input on
energies present at conception and Ming Men (Fire of Life); Dr Henry Lu for his response to my enqui-
ries regarding his translation of the Nei-Jing and Nan-Jing; Alan Hext for discussions regarding the qi
jing ba mai; Wainright Churchill for recommending the scholarly works of Russell Kirkland; Russell
Kirkland for providing a range of his articles and collaborating with me; Tony Booker for reviewing
the TCM energetics of food section; Care Fertility, Nottingham, for the images of eggs, sperm and
embryos and for looking after my patients so well; and Davey Podmore, my neighbour, for the pro-
fessional drawings of the TCM figures what a palaver that was!
The most exciting thought as I write now for the last time is the closure of this chapter of my life and
in turn I hope that our book opens up new chapters in the life of subfertile patients.
Lianne Aquilina
xviii
Chapter |1|
Subfertility overview
Being a reproductive medicine acupuncturist is both pregnancy’.1 The European Society of Human Reproduc-
rewarding and challenging – rewarding because we make tion and Embryology (ESHRE) definition is ‘a pregnancy
a real difference in other people’s lives. We help them diagnosed by ultrasound or by definite signs of pregnancy’.3
achieve their greatest dreams and become part of a team The American Society for Reproductive Medicine (ASRM)
that helps to bring new life into the world. It is challenging defines pregnancy as ‘a clinical pregnancy documented by
because it takes a lot of dedication and determination to ultrasonography or histopathologic examination’.2
effectively help those suffering from infertility. If a woman experiences ‘pregnancy signs’ such as delayed
In this book, we hope to share with you the knowledge menstruation, nausea, swollen and tender breasts, yet a
and experience that we have gained during our two decades pregnancy test result is negative, should this be classed as
of specializing in ART acupuncture. We begin by introduc- ‘clinical pregnancy’? Definite clinical signs of pregnancy
ing you to infertility and explaining exactly what this dis- can be evident within days of ovulation, yet up to 60%
ease is and what causes it. of pregnancies will fail even before they are confirmed by
a pregnancy test.5 Ultrasonographic evaluation is not usu-
ally utilized until 12 weeks gestation, by which time up to
DEFINITION OF INFERTILITY 70% of pregnancies fail.5 So whilst WHO includes in its
DISORDER definition ectopic pregnancies, this may be inappropriate
and more than just a tautological oxymoron. For example,
if a woman loses both fallopian tubes as a result of ectopic
Most medical organizations agree that infertility should be pregnancies, she will be completely sterile. Yet by WHO’s
defined as the inability to conceive after 1 year of regular definition, she will be classed as fertile!
unprotected intercourse (see Table 1.1). However, this def-
inition can be confusing and open to varied interpretation.
Definition of regular intercourse
Definition of pregnancy The meaning of ‘regular unprotected sexual intercourse’ is
another area for confusion. One couple may perceive that
Success in the field of reproductive medicine is defined as,
intercourse every 4–5 days is regular, whereas another cou-
for example, a ‘clinical pregnancy’, a ‘successful pregnancy’,
ple may consider regular to be daily intercourse. What is
and ‘conception’. So what is meant by ‘clinical’ or ‘success-
probably more important is the timing of intercourse in
ful’? The World Health Organization (WHO) defines a
relation to the menstrual cycle. Frequent intercourse during
clinical pregnancy as ‘a pregnancy diagnosed by ultrasono-
the fertile window (usually starting 5 days before and fin-
graphic visualization of one or more gestational sacs or
ishing on the day of ovulation) is most likely to result in
definitive clinical signs of pregnancy. It includes ectopic
conception.6–12 Intercourse outside of the fertile window
is almost certainly unlikely to lead to pregnancy.11
Table 1.1 Definition of infertility
2
Subfertility overview Chapter |1|
compare the results of research studies due to heteroge- not find any evidence of this, except for secondary infertility
neous groups of patients. (difficulty conceiving after successful live birth).22
Once a couple is diagnosed as infertile, they may experi- One of the possible explanations for differences in opin-
ence significant psychological consequences. The term ions about infertility trends is that different research studies
infertility is often associated with total sterility and implies use different measures of fecundity. Historically, the time
a complete inability to conceive. Yet, in reality, the degree from marriage to pregnancy was used. Nowadays, espe-
of infertility will vary, and the term infertility covers a spec- cially in developed countries, couples delay parenthood
trum from mild subfertility to complete sterility. until they are more economically secure. Therefore, time
In acupuncture practice, patients often present with from marriage to pregnancy is no longer a relevant mea-
‘infertility’, either medically or self-diagnosed. We would sure. Time to pregnancy is now used as a measure of fecun-
caution practitioners not to rely on such a diagnosis too rig- dity. te Velde et al. argue that time to pregnancy in ‘carefully
idly. Taking a thorough medical history from which we can selected populations is a feasible option’ to find out if the
assess the appropriateness and the severity of the diagnosis level of fecundity is declining.25
is paramount. There are also reports that male fertility, measured by
In reproductive medicine, the terms subfertility, subfecund- sperm counts, has decreased significantly.26 However,
ity, and even sterility are usually used synonymously with because of heterogeneous measurement methodology,
infertility. In this book, we use the terms subfertility and infer- such as comparing data from different populations and
tility interchangeably to refer to suboptimal fertility and to using different methods of sperm analysis, this finding
describe varying degrees and durations of involuntary child- has been questioned by some.27
lessness in varying patient groups. We use the term sterility to Different types of infertility vary between countries. For
indicate absolute inability to have a genetically related child. example, age-related infertility is becoming more prevalent
in the more developed nations, secondary infertility is virtually
nonexistent in China because of the one-child policy, and
primary infertility is very low in Africa, where women are
PREVALENCE OF INFERTILITY exposed to STIs only after they marry and have their first baby.19
3
Acupuncture for IVF and Assisted Reproduction
Male and
female factor
39%
Female factor
33%
factor,20,32 25–40% is due to both male and female fac- common symptoms and medical conditions acupuncturists
tors,20,21,32 and in 8–20% of cases no cause can be identi- frequently deal with in patients presenting with subfertility
fied (Figure 1.1).20,32 are irregular cycles, polycystic ovaries, and endometriosis
The most common medical causes of female subfertility are (female factor); abnormal sperm (male factor); and unex-
ovulatory disorders (20–32%),21,33 tubal disorders (14– plained infertility (both male and female factors).36
26%),21,33,34 and endometriosis (5–6%) (Figure 1.2).21,33 Tubal disease, which accounts for up to 26% of causes of
The most common medical causes of poor semen param- female subfertility,21 was not reported as a common pre-
eters in men include cryptorchidism (13%),35 varicocele sentation in acupuncture practice. Paradoxically and inter-
(10%),35 congenital abnormality of the vas deferens estingly, a 2010 study found that acupuncture during
(4%),35 and endocrine abnormality (2%).35 In 57% of embryo transfer resulted in a higher pregnancy rate in
men with severe oligospermia or azoospermia, no causes tubal-uterine or idiopathic cause cases.37
are found (Figure 1.3).35
21%
14%
6%
4
Subfertility overview Chapter |1|
13% 13%
10%
4%
2%
factor, it is still the female partner who comes for acupunc- There is a well-documented trend that women in such coun-
ture. As acupuncturists, we need to be aware that in two out tries are delaying motherhood until later in life. The mean
of three couples we treat, there is likely to be a male-related age of a mother giving birth to her first child in England
subfertility cause, either alone or in combination with a and Wales was 23.7 in 1970 and has steadily increased to
female factor. 28.0 by 2011.38 The data from the United States is compa-
Conventional reproductive medicine practice is often rable, 21.4 in 1970 to 25.0 in 2006.39 Similar trends have
guilty of ignoring the issue of male fertility. Most men have been reported in other countries, including Switzerland,
their semen analysed, but, in many cases, if the semen is Japan, Netherlands, Sweden, Italy, Ireland, Greece, Den-
found to be suboptimal, these couples are automatically mark, Finland, Canada, France, Hungary, and Poland.39
referred for IVF, rather than the man undergoing further Delaying parenthood until later in life can have a num-
investigations to see if a cause of poor semen parameters ber of advantages. For example, commonly cited reasons
can be found and corrected. There is a belief that IVF some- are that the prospective parents are more financially and
how magically overcomes male factor infertility. In part this emotionally able to cope with bringing up a child and
is true, especially since the development of Intracytoplas- are in a more stable relationship.40,41
mic Sperm Injection (ICSI). However, the success rates However, fertility declines with age in both men and
for IVF in male factor couples are only slightly higher than women. Ovarian reserve declines rapidly after the age of
in couples with other causes of subfertility. 35.42 Older men have lower sperm parameters and higher
rates of sperm DNA damage.43 Conception has a higher
CONTRIBUTORY SUBFERTILITY risk of complications in pregnancy and during delivery in
reproductively older women. For example, one multicentre
FACTORS: THE ORTHODOX MEDICAL European study found that miscarriage rates were highest
PERSPECTIVE in couples where a woman was aged 35 or older and a
man was 40 or older.44 Pregnancies fathered by older
Many factors contribute to infertility, including cultural, fathers have been linked with higher rates of caesarean sec-
social, economic, and environmental. Different factors tions, preeclampsia, and preterm birth,43 even after taking
may contribute to varying degrees in different populations into account the age of their partners.
and at an individual level at different stages of the repro- Children conceived by older parents are also at higher
ductive cycle and reproductive development. risk of health complications, including birth defects, child-
hood cancers, prostate and breast cancers, type I diabetes
Socioeconomic factors mellitus, multiple sclerosis, some forms of cerebral palsy,
schizophrenia, bipolar disorder, autism, epilepsy, Alzhei-
Delayed parenthood mer disease, and lower intelligence. However, some of
Delayed parenthood is perhaps one of the biggest contrib- these associations need to be researched further to confirm
uting factors to subfertility in more developed countries. these findings.43 Babies born to women aged 40 or more
5
Acupuncture for IVF and Assisted Reproduction
have a higher risk of being born prematurely, having a Limited healthcare budgets also affect the availability
lower birth weight, and being admitted to intensive care and access to subfertility treatments, such as assisted repro-
units. Genetic abnormalities such as Down syndrome ductive technologies. Poorly educated people may not be
occur more often in children conceived by older mothers. aware of reproductive treatments, or they might not be able
The trend to leave parenthood until later in life might to pay for them if these are not funded by the state. Also,
have been influenced by the availability of ART treatments there may be stigma attached to using reproductive treat-
and the erroneous perception by many that IVF will ‘fix’ ment services.
them should they have difficulties conceiving.45 However,
IVF is less successful in older women, with live birth rates
39% in women aged 34 or younger, going down to just Traditions, culture, and family values
4% in women aged 43 or older.46 There are many reasons why people choose to have
children. Different cultures place different values on family
Education and financial status life and parenthood. In some cultures, the only purpose
people have in life is to reproduce and have as many chil-
Poor education and illiteracy result in women having lim-
dren as they can. For some, it is insurance for when they are
ited or no access to family planning services and to contra-
older, perhaps to have workers to help with domestic
ception. This results in high rates of Sexually Transmitted
chores. For others, it is to ensure longevity of their family
Diseases (STDs), unwanted pregnancies, and septic abor-
name. Often people choose to have children because it is
tions leading to subfertility. There is also some evidence
what is expected of them by their family or society.
that socially deprived people take longer to conceive.47
Some traditions in some parts of the world are blamed
More educated couples are more likely to have access to
for adding to subfertility rates. For example, female circum-
knowledge about the menstrual cycle and how to optimally
cision is still widely practised and affects 80 million
time their intercourse to conceive. This knowledge can lead
women, mostly in Africa.48 Female circumcision is often
to better coital practices, but, conversely, it can also put
performed by people without knowledge of hygiene or
pressure on partners to ‘perform’ on demand and, there-
anatomy and in many cases leads to haemorrhage, infec-
fore, negatively affect their fertility psychology.
tions, and subfertility. Even if these circumcised women
get pregnant, there are often complications during labour,
Political policies resulting in haemorrhage, shock, and perinatal maternal
In an attempt to control population growth or decline, some deaths.48
governments put in place population-control policies. For
example, for many years, China has maintained strict con-
trol of population growth through a one-child policy.
Environmental factors
Opposite trends can be observed in other countries. Pollution can affect fertility and reproduction at different
Many developed countries see a decline in overall numbers stages and in different ways. Exposure to environmental
of births while in the general population life expectancy is contaminants can happen in utero, during the develop-
increasing. The trends in couples in these countries to delay mental years when the reproductive organs grow and
having children until later in life can lead to an increase in mature, and also in adulthood. Certain environmental haz-
the number of cases of age-related subfertility. Thus, some ards are linked to sperm issues, menstrual cycle irregulari-
governments encourage couples to have more children ties, hormonal changes, miscarriages, foetal loss, early
through financial and employment incentives. menopause, malformations of the reproductive tract, endo-
metriosis, fibroids, altered puberty, and other reproductive
Healthcare spending changes.49
Men are possibly affected by exposure to environmental
In third-world countries, spending on healthcare is low,
oestrogens, both at puberty and continually through their
and, consequently, medical care is poor. This can affect fer-
lives. This oestrogen may have an effect on the hypotha-
tility in a number of ways. Poor family planning services
lamic pituitary axis and spermatogenesis.18
lead to many unwanted pregnancies, which often results
More detailed information on which environmental pol-
in many illegal abortions. Badly done, these can lead to
lutants and chemicals have been linked with subfertility
infections and scarring. Limited services mean that STDs
can be found in Chapter 7.
are not diagnosed early enough and, thus cause tubal
and ejaculatory duct damage. Reconstructive surgeries for
this type of damage are often unsuccessful. Preventative
Occupational factors
measures, such as better sex education, improved diagnosis
and treatment of STDs, and better family planning services Certain occupations are associated with reduced fertility.
(including availability of contraception) could all help to Primarily this is through contact with environmental
reduce the rate of STDs and unwanted pregnancies.48 hazards.
6
Subfertility overview Chapter |1|
Sedentary occupations have increased over the last cen- sperm.55 Chapter 7 provides more detail about the fertile
tury and are associated with an increase in intra-scrotal window, intercourse, and coital practices.
temperatures. Raised intra-scrotal temperature damages
sperm DNA in animals. There is some evidence that a sim-
ilar effect can be seen in human sperm.50
Reproductive tract infections
The level of evidence for occupational hazards varies, The presence of microorganisms in the reproductive tract
and more research is required to definitely determine cau- can cause it to become infected. Microorganisms can also
sality. More detailed information on which occupations be introduced during sexual intercourse, usually referred
have been linked with subfertility can be found in to as STIs or STDs, or through a medical procedure.56
Chapter 7. WHO estimates that in 1999 there were over 340 million
new cases of the four curable STIs (gonorrhoea, chlamydia,
syphilis, and trichomoniasis). Viral STIs such as human
Overview of other factors papilloma virus, herpes simplex virus, and human immu-
nodeficiency virus were not included in the estimate. If
Increased stress levels these were included, the number of STI cases might be three
Stress may be linked to reduced fertility. However, opinions times higher.56
vary about this. Chapter 7 reviews the evidence on the STIs are one of the biggest causes of subfertility in men
effects of stress on fertility in greater depth. and women. WHO estimates that the risk of infertility after
one episode of pelvic inflammatory disease (a common
complication of STIs) is increased by 15–25%, and it rises
Nutrition, weight, and exercise to 50–60% after a third episode.56 STIs can also cause
Being over- or underweight has been linked to subfertility maternal deaths, miscarriages, stillbirth, preterm birth,
and congenital infections.56
and obstetric complications.18
Moderating exercise levels and keeping weight appropri- Delaying sexual activity, reducing the number of sex part-
ners, correct and consistent use of condoms, and better
ately controlled may help to reduce the risk of ovulatory
disorders.51,52 hygiene practices in medical settings, particularly in poor
countries, are some ways to prevent STIs.56
A nutritionally rich diet helps to improve fertility in both
men and women.51
The roles of stress, nutrition, weight, and exercise are Negative lifestyle habits
reviewed in much greater depth in Chapter 7.
Negative lifestyle habits, such as smoking, drinking exces-
sive amounts of alcohol, and using recreational drugs are
Early puberty linked with increased time to conception. Chapter 7 dis-
cusses this in more detail.
An increased caloric intake and possible exposure to envi-
ronmental oestrogens may be responsible for some causes
of early female puberty and may potentially result in a CAUSES OF SUBFERTILITY FROM THE
shorter reproductive lifespan.18 Girls who reach puberty
TCM POINT OF VIEW
early are more likely to be overweight, have Polycystic
Ovarian Syndrome, fibroids, or endometriosis, all of which
are linked to subfertility. Early puberty may also lead to In Traditional Chinese Medicine (TCM), health is achieved
early sexual activity with associated unwanted pregnancies by maintaining a delicate balance between Qi (life force or
and abortions or STDs, all of which can lead to infertility. energy) and the body, mind, and spirit. This delicate bal-
ance can be affected by numerous factors categorized into
Internal, External, and Miscellaneous causes.57 Once health
Sexual intercourse is affected by these factors, according to TCM, it will begin
to deteriorate and, if left untreated, will eventually cause a
It is estimated that 15% of couples will not conceive
disease.
through any method other than ART. For the remaining
85%, conception should be possible through regular sexual
intercourse.53 Their chances of conception will be greatly Internal causes of disease/injury
affected by the frequency and timing of their intercourse.54
through emotion
The use of water-based lubricants such as KY Jelly, olive
oil, and even saliva is not advisable because sperm can be An Internal cause of a disease arises as a result of excessive
damaged by their presence. Mineral oils (such as canola emotions.58 Experiencing emotions is necessary and
oil) and hydroxyethylcellulose-based lubricants (such as healthy. However, excessively strong emotions can cause
Pre-Seed®) do not appear to have detrimental effects on an imbalance of Qi, Qi Deficiency,59 impaired Blood
7
Acupuncture for IVF and Assisted Reproduction
circulation,58,60,61 and dysfunction of the Zangfu organs62; adversely effecting fertility. Spleen Qi Deficiency can lead
it can also affect the balance of Yin and Yang.60 to Internal Dampness, especially in the lower Jiao. Damp-
Reproductive energy is the source of new life.62 Suffering ness from Spleen Qi Deficiency can cause Phlegm. Substan-
from infertility has an emotional impact on a couple. This tial accumulation of Damp-Phlegm clogs and blocks the
emotional imbalance can damage the Zangfu organ system, Uterus, causing subfertility by hindering the vital flow of
depleting and reducing reproductive potential.62 A combi- energy necessary for fertilization, conception, and preg-
nation and a range of emotions may impact the person in nancy.58 Fear combined with worry can injure the Heart.70
various ways. TCM recognizes that many emotions (for Fertility and IVF can be a source of worry for couples,
example, excessive joy or unexpected joy or anger)63 can especially for those who have experienced prior difficulties
be pathological64 but generally views pathological emo- with ART. Such couples worry about producing enough
tions as: eggs or sperm, eggs being fertilized, the number of or
• Anger65 whether embryos will be available for transfer, whether
• Contemplation or worry62 the embryo(s) develop(s) to the blastocyst stage, the preg-
• Sadness and grief64 nancy test, and possible miscarriages.
• Fear64
• Shock66 Anxiety
Women are particularly prone to internal injury by emo-
Anxiety impairs the Spleen, the Kidney, and the Heart. By
tion,67 which is why women often require a great deal of
weakening the Spleen, anxiety can cause Blood Defi-
support when dealing with subfertility:
ciency,61 thus impacting upon fertility.
• Women’s Qi and Blood physiology make them
susceptible to injury by emotion.
• Particular constitutional tendencies and pre-existing Fear
syndromes may predispose women to experience Fear affects the Kidneys, often leading to Kidney Yin Defi-
particular emotions (for example, women who are ciency.68 Fear or being fearful is like a stimulant, depleting
Wood/Liver type may feel angry, moody and irritable). Kidney reserves. Fear disperses and weakens Shen
• Women may respond to subfertility in a reactive (Spirit).62 A Deficiency of Liver Qi can cause Fear.62
manner. This may be considered a normal reaction, but Sudden fright can descend Kidney Qi,61 and chronic fear-
how they feel about the situation and cope with it may fulness can make Qi ascend, causing a deficiency of Blood
eventually lead to major ill health. or Yin.68
• Women are extra sensitive to the emotional upheaval of Some patients, even before they start trying for a baby,
ART, and this can be further exacerbated by hormonal fear they may not be successful. ART patients may fear
medication. the medical procedures involving numerous injections or
• Damage to Zangfu organs by excessive emotions causes be frightened of taking a pregnancy test. The effects of pro-
Yin Deficiency62 and a loss of reproductive energy. longed suffering from fear negatively impact the reproduc-
tive system.62
Anger
Anger includes feelings of frustration and irritation. These
Sadness and grief
feelings have a tendency to directly increase Liver Qi,65 Sadness affects the Lungs,61 the Liver,62 and the Heart and
causing Liver Qi Stagnation, Liver Fire, Liver Blood Stasis, may influence the functional relationship between these
or Blood-Heat.68 Anger makes energy rise upwards, which organs.68 Sadness and grief induces Heart and/or Liver Blood
further damages the Liver.69 An imbalanced Liver can neg- Deficiency and may also impact the functions of the
atively affect the regulation of the menstrual cycle and the Uterus.68 Deficiency of Heart Qi can cause sadness.62 Sad-
Spleen’s function of transportation and transformation of ness exhausts the meridians linked to the womb and causes
food and fluids,61 leading to Qi Deficiency. infertility. Excessive sadness may injure the entire internal
Feelings of frustration and resentment can present in a organ system, leading to an overall deficiency of energy.
woman suffering with infertility and failed ART. Being aware Feeling disappointed and sad is common in subfertile
and hypervigilant to the presence of pregnant women, patients. They grieve for what could have been and what
babies, and celebrities with big ‘bumps’ can make subfertile they do not have. Each time a pregnancy test is negative,
women feel frustration, anger, jealousy, and resentment. they may go through periods of grief, sadness, and sorrow.
8
Subfertility overview Chapter |1|
Women who had an abortion when they were younger Spleen stores intention and sentiment. The Kidneys store
may feel guilty, incorrectly associating their infertility with Jing (Essence) and will (Table 1.2).72
the abortion. They feel like they are being punished for Fright, fear, nervousness, deliberation, and worry cause
what they have previously done. injury to the Shen (Spirit).62 All these emotions are very
Both male and female partners can also experience guilt common in subfertile patients.
individually if they are the ones ‘at fault’. They can also feel A compromised Shen (Spirit) can also cause an emo-
guilty for failing their other half or failing their parents by tional imbalance and ill health. For example, a weak Spirit
not providing a child or grandchild. can cause fear, which can induce seminal emission, affect-
ing the reproductive system in men.
In order to identify the syndrome(s) and derive appropri-
Interrelationship between the emotions, the ate treatment principles, acupuncturists should try to corre-
body, and the Spirit late the sound of a person with their colour, odour, the
The relationship between the emotions, the body, and the relationship with Spirit, emotions, and the Zangfu organ
Spirit is complex: system because these interact with each other (see
Chapter 5).
• Emotions can cause the disease and/or injure the Spirit.
• Zangfu organs produce Qi responsible for emotions.64
• Physical pathology can cause an emotional imbalance.
• A compromised Shen (Spirit) can affect the External causes of disease
emotional balance and/or cause a disease. External Pathogenic Factors (EPFs) are the beginning stages
• The Zangfu organs store Jing (Essence); when they of disease.76 A disharmony arises as a result of External
are injured through emotion, reproductive Qi is lost.62 causes when the body is invaded by EPFs or Six Evil Qi.
With subfertile patients undergoing ART, determining the EPFs tend to invade the body when it is weak,77 not well
cause and effect is even more difficult. ART treatment is protected, or exposed.
often referred to as an emotional rollercoaster, forcing Fertility could be particularly compromised when the
patients to experience short-term immense joy and hope, EPFs invade the Uterus. EPFs enter the Uterus directly or
followed by despair soon after, followed by more emo- invade the space between the skin and muscles.68 There
tional ups and downs. The acupuncturist’s task in such are various traditional concepts regarding EPFs’ transmis-
situations is to identify primary causes of disease caused sion of disease. One example is where EPFs enter deeper
by emotion and acknowledge and prevent additional path- into the body, finally ending up in the meridians, the five
ological emotions, which could cause a new disease or Zang organs, and then the Stomach.78
exacerbate pre-existing imbalances. The EPFs Wind-Cold, Cold-Damp, and Damp-Heat can
‘Examine the syndromes to find the cause’ serves as a cause Girdle vessel (vaginal) discharges.58 Vaginal dis-
good guide when determining primary or secondary causes charges influence Bodily Fluids that exit58 and reproductive
of subfertility.66,71 Examining the state of Shen (Spirit) of a energies that enter the vagina. Girdle vessel discharges are
person provides a useful example of this process. not dissimilar to the Orthodox medical concept of vaginal
The Zangfu organs encompass physical, spiritual, and discharges caused by bacterial and viral infections.58 Vagi-
emotional aspects of each person. They are referred to as nal discharges can induce complexity of disease and reduce
storerooms because Spirits reside in and are stored there. fertility further by transferring to the Chong Mai (Penetrat-
The Heart stores Shen (Spirit), and the Lung stores strength. ing Vessel) and Du Mai (Governing Vessel) and then enter-
The Liver stores mental consciousness, the soul and the ing the rest of the body.58
9
Acupuncture for IVF and Assisted Reproduction
A woman is thought to be more prone to an EPF invasion Heat tends to affect the flow of Blood by speeding it up
during menstruation61,68 or following childbirth.61 EPFs and making it ‘reckless’. Once Heat has entered the body, it
are: can move into the Blood-level, causing Blood-Heat,68 thus
• Wind65 adversely affecting fertility. Heat can be retained at a low
• Coolness/Cold65 level for long periods, causing subfertility. Heat can affect
• Heat/Fire65 male fertility by negatively affecting sperm production.
• Dampness65
• Summer-Heat65
Damp EPF
• Dryness59
Damp living environments or being in a wet damp climate
Temperature and climatic factors71 directly influence
for prolonged periods can give rise to Damp invasion.81
Blood. A Cold climate may congeal and stagnate Blood,
Dampness can invade the lower part of the body
while Hot climates may stir up Blood. A Windy climate
directly68,80 or descend to the lower part of the body.80
can deregulate the menstrual cycle.58 EPF Wind harms
Dampness damages the Lower Jiao,65 blocking the flow
the Liver.79
of Qi and Blood to the reproductive organs.
Invasion by Cold, Heat/Fire, or Dampness EPFs is a com-
mon cause of subfertility.61,68
Miscellaneous causes of disease
In TCM, a disease can also arise as a result of miscellaneous
Cold EPF
causes. Miscellaneous causes include:
Cold EPF enters the body from the surface of the body into
• Weak constitution
the interior of the body.80 Cold invasion can occur from
• Unhealthy lifestyle habits
being in a cold environment for a long period or wearing
• Poor diet and nutrition
inadequate footwear or clothing. If a woman sits on a cold
• Surgery
or damp surface for long periods, she may also suffer Cold-
• Physical overexertion
Damp invasion. Coolness is harmful to the lower Jiao.65
• Too much work and not enough rest
Cold medical instruments can also introduce Cold inside
• Previous fertility treatment
the Uterus.
• Miscarriage
Cold is harmful to Blood.64 Cold contracts and coagu-
• Coitus and inappropriate family planning
lates Qi and Blood, leading to Qi or Blood Stagnation. Stag-
• Contraception
nation can damage the Extraordinary Vessels, particularly
the Chong Mai (Penetrating Vessel) and Ren Mai (Concep- However, Sivin argues that mental overstimulation, unre-
tion Vessel).61 Both these Vessels are essential for fertility gulated diet, and overexhaustion are all External causes
and pregnancy. of disease.71
In men, Cold can cause seminal Essence-Cold, affecting
men’s fertility.58 This Cold semen can then enter the Uterus Constitution
during intercourse, creating difficulty in retaining semen58
or inducing a Cold Uterus. The patient’s state of health varies, depending on the con-
A Cold Uterus (whether arising from Cold EPF or from stitution passed on to the patient by his or her parents.61
internal dysfunction) destroys ‘things’, including semen The constitution of a child can be weaker if its parents were
entering the Uterus, and, if conception progresses to this older or ill at the time they conceived that child. A weak
stage, the foetus.58 A Cold Uterus is also unable to regulate constitution can affect most bodily systems, including
Jing (Essence), causing conception difficulties.58 This pre- the reproductive system.
sentation is evident in some women with fertilization Different constitutions and the influence of lifestyle gen-
and embryo development issues, Repeated Implantation erate various physiques that determine susceptibility to
Failure, and reproductive immunology issues. invasion by EPFs.61
Various imbalances in the constitution of individuals can
be strengthened with acupuncture with appropriate need-
ling technique, the use of herbal medicine, and improve-
Heat/Fire EPF ments in lifestyle, diet, and exercises61 such as qigong
Heat/Fire EPF can occur through climatic changes or hot and tai chi.
environments. Heat or Fire is harmful to Qi.64 Heat/Fire Constitutional Deficiencies of the Kidney (for example,
can consume Qi and Bodily Fluids and damage the Extraor- Kidney Yang Deficiency in the male and Kidney Yin Defi-
dinary Vessels. In particular, it can affect the functions of ciency in the female) affect the transformation of vital ener-
the Chong Mai (Penetrating Vessel) and Ren Mai (Concep- gies essential for fertilization and conception. Poorly
tion Vessel). transformed vital energies may cause infertility because
10
Subfertility overview Chapter |1|
the foetus is unable to take form.58 Conceptionally, this Work and rest
may be similar to poor fertilization rates or failure of
Overwork can consume Qi61 and disperse Yang Qi.79 Too
embryos to implant.
much rest can Stagnate Qi.61 Working long hours and not
getting enough rest can cause Kidney Yin Deficiency68 and
Inappropriate diet affect the Liver and Heart, particularly if the work is per-
ceived as stressful and is combined with a busy personal
Irregular eating and excessive fatigue damage the Spleen
lifestyle.
and may cause extreme Deficiency82 in several Zangfu
A physically demanding job can cause Kidney Defi-
organs, thus reducing reproductive potential.
ciency, impacting reproductive health. Sitting for long
The temperature of foods and fluids can influence the
periods can cause Lung and Spleen Qi Deficiency. The psy-
body in a way that causes pathology. Foods that are too
chosocial dynamics of the work environment can impact
hot or too cold in temperature can produce the same phe-
the well-being of a person, especially when exposed to mis-
nomena inside the body, i.e. hot foods generating Heat,
treatment, intimidation, and pressure to perform. This
and cold foods generating Cold.
often produces Spleen Qi Deficiency and Liver Qi
Although TCM literature states that ‘improper diet’ is
Stagnation.
caused by excessive consumption of hot, cold, and raw
Physical overexertion can cause infertility and reduce
foods or overeating,61,68 even mild consumption of Cool
reproductive potential. This is especially so for a certain
or Hot foods over a period can have subtle implications
subgroup of patients, for example, patients with Yin Defi-
on a patient’s ability to conceive. However, eating and
ciency who are undergoing ART and have very busy work
drinking hot and cold foods in moderation83 and on a reg-
and personal lifestyles. A balance between activity and rest
ular basis maintains harmony between the body and Shen
helps preserve Kidney Jing (Essence)83 and Yin and there-
(Spirit).84,85 Dieting can cause Deficiency of the Stomach
fore fertility.
Qi, Deficiency of Jing (Essence), and low Shen (Spirit).60
Couples may delay starting a family because of career
From a TCM perspective, dieting or vegetarianism leads
pressures. This reduces fertility purely because of an age-
to Blood Deficiency.68 Although vegetarians may still get a
related natural decline in fertility as, by the age of 40,
range of nutrition from a well-balanced vegetarian diet, a
Kidney Yin is significantly reduced.64
diet without TCM Blood-nourishing properties can pro-
For some people, being overworked and needing to have
duce Blood Deficiency.
constant communication (such as emails, mobile phones)
Consumption of greasy foods will impact the bodily sys-
combined with inadequate rest and sleep, uses up more
tems, especially in patients with pre-existing conditions
Blood from the Liver and Heart. This decreases Blood
such as Spleen Qi Deficiency, Dampness, or Phlegm.
and Jing (Essence) and the amount of nourishment avail-
Greasy foods tend to create Dampness in the Lower Burner.
able to the body.86
A high intake of cheese, butter, cream, bananas, sweets, and
sugar causes Dampness in the body.68,71 These turbid ener-
gies of food damage the Middle Jiao.80
Previous fertility treatment
Surgery Previous fertility treatment can weaken Yin, Yang, Qi, and
Blood. It can also lead to Heat and Stagnation. The Shen
Some women may have undergone surgery prior to ART. (Spirit) is easily disturbed by these factors, and it can be
Surgery can create Qi or Blood Stagnation in the Lower Jiao. affected by the emotional consequences of failed ART
Stagnation can affect several Meridians and Extraordinary treatment.
Vessels and the Uterus, as well as alter the physiological
dynamics of Zangfu interrelationships.
Surgery can have an emotional element attached to it,
affecting how women feel, and this connects with the Miscarriages
Lower Jiao, potentially causing Heart-Uterus imbalance. Miscarriages are believed to be as draining to Qi and Blood
as childbirths.68 They affect the Kidney, Heart, and Liver
and lead to Kidney Qi Deficiency, Blood Deficiency, or
Social, recreational, and physical overexertion Stagnation.
Physical overwork can induce Stagnation or Deficiency. This Early miscarriages damage the Kidney, consume Qi, and
is especially so if it occurred during puberty, for example, in weaken the Blood.61
young dancers68 or young athletes. Such overexertion can Miscarriages usually happen in the background of pre-
have long-lasting effects. In adults, excessive exercise injures existing maternal Deficiency of Qi and/or Blood. The emo-
the Spleen, Liver, and Kidneys.68 This is a common occur- tional impact for some women suffering from a miscarriage
rence and delays conception in runners or people active in can create Heart Blood Deficiency, contributing to further
sports through the formation Qi Deficiency. subfertility and further miscarriage.
11
Acupuncture for IVF and Assisted Reproduction
12
Subfertility overview Chapter |1|
1950s 1983
Sperm capacitation Birth from
discovered cryopreserved embryo
1984
GIFT developed
1967 1983
Clomid licensed Donor egg baby born
promises even better results than ICSI.97 Morphologically viewed as a form of power in society. In pre-industrial Chi-
optimal sperm are identified using microscopy and nese society, birth rates and death rates were high, and the
injected into the egg, theoretically reducing the possibility growth rate of the population was therefore low.98
of poorer quality sperm being used. The notion of Yin and Yang represents the zenith of fertility.
In 2004, the first birth from transplanted cryopreserved Yin and Yang exemplify male and female sexual organs. Yin is
ovarian tissue was reported.95 female, and Yang is male.98 Yin Yang philosophy extends
ARTs are evolving rapidly, and many other techniques have throughout the treatment and management of infertility.
been and are in the process of being developed. Figure 1.4 When advising men and women on how to optimize their
highlights major milestones in the development of ART. fertility in order to reproduce, the concept of Yin Yang phi-
Currently, researchers are focusing on fertility preserva- losophy is an integral part of fertility treatment. The male’s
tion, genetic diagnosis, improvement of ART success rates, fertility is thought to ‘fluctuate on a daily basis correspond-
and stem cell treatment of major diseases. ing with the rising Yang energies, particularly in morning’.99
In 2010, ESHRE estimated that since the birth of the first The male is responsible for providing the ‘Essence for
test tube baby, over 3.75 million babies have been born as a conception’ while the female takes charge of ‘gathering
result of IVF.20 the Essences’.58
13
Acupuncture for IVF and Assisted Reproduction
Table 1.3 Summary of key TCM physicians and texts relating to gynaecology
14
Subfertility overview Chapter |1|
Table 1.3 Summary of key TCM physicians and texts relating to gynaecology—cont’d
Continued
15
Acupuncture for IVF and Assisted Reproduction
Table 1.3 Summary of key TCM physicians and texts relating to gynaecology—cont’d
16
Subfertility overview Chapter |1|
10 years after puberty in women.99 Men were encouraged caused by the fact that people delay having children until
to marry at 30 years of age because that is when their fertil- later in life.
ity was believed to be in its prime.99 As the numbers of people requiring ART has increased, so
have the numbers of patients presenting for supportive acu-
puncture treatment during ART. Research suggests that
Importance of optimizing natural fertility these numbers are likely to rise further. This demand is
in part fuelled by reports of several studies showing that
Classical TCM teachings recognized the importance of pres-
acupuncture has a positive effect on IVF success rates.
ervation and optimization of natural fertility.99 The female
TCM understanding of gynaecology and fertility goes
was assigned procreative potential.58
back several millennia. TCM provides a different and alter-
native perspective on subfertility that has much to offer the
subfertile couple on their journey toward conception.
Integrated approach However, as with Orthodox medicine, the knowledge
Since 1949 in China, TCM has been well integrated into about how to manage patients during ART is a relatively
Orthodox medicine. Acupuncture is often administered modern concept, one that is rapidly evolving.
in hospitals. Doctors decide on the treatment plan, often Infertility and ART is a challenging field of medicine.
combining the best of the Orthodox and TCM medical Neither Orthodox medical nor TCM medical paradigms
approaches. In the West, integrative approaches are have all the answers. An integrated approach, where acu-
extremely underused. This is especially so in ART medicine, puncturists have a thorough understanding of both con-
where the potential for success may well be improved by cepts of reproductive health, may prove to be the most
the integration of TCM and Orthodox medical approaches. clinically useful approach. For example, when taking an
initial medical history, acupuncturists must enquire into
nonmedical causes of subfertility using both health
models. A combined Orthodox medical and TCM
SUMMARY approach to the assessment and management of subfertility
enhances patient care by providing a holistic integrated
Rates of infertility appear to be static, yet increasingly approach and promoting optimal health, fertility, and
more couples require ART treatments. This is in part well-being.
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Chapter |2|
Anatomy and physiology of the reproductive
system: Prerequirements for conception
Many patients with fertility issues like to know precisely • Uterus (womb)
what is happening in their body and how this is related • Vagina
to their ability to conceive. In this chapter, we will explain
the key elements of human reproductive anatomy and
physiology, which are essential for fertility acupuncturists The ovaries and follicles
to understand. Orthodox medical and Traditional Chinese The ovaries are two glands. The male equivalent is the tes-
Medicine (TCM) concepts in relation to reproductive ticles. Each ovary lies on the lateral side of the pelvis. The
structure and function will be explained. ovaries were first described by Soranus, a gynaecologist
living in the Roman Empire in the second century CE.1
FUNCTIONAL ANATOMY OF THE The ovaries are approximately 2.5–3.5 cm long, 2 cm wide,
and 1 cm thick2 or the size of an unshelled almond.3 The
REPRODUCTIVE SYSTEM FROM AN ovaries are attached to the uterus by the ovarian ligaments
ORTHODOX MEDICAL PERSPECTIVE and by the suspensory ligament to the pelvic wall. The
uterus and the ovary are attached by the broad ligament.3
The main function of the ovaries is to develop and
Female reproductive anatomy
mature eggs (oocytes), which are then released, usually
The main functions of the female reproductive system are: one egg at a time, during a process called ovulation. Each
• Production of eggs (oocytes) ovary contains two main types of tissue: the medulla and
• Fertilization of an egg by a spermatozoa the cortex. The medulla is the central part of the ovary
• Providing an environment for nourishment, growth, and contains fibrous tissue, blood vessels, and nerves.
and development of an embryo and foetus The cortex surrounds the medulla and contains ovarian
• Childbirth follicles (folliculus ¼ little bag),3 all at various stages of
development and maturation.2 Each follicle contains an
The female reproductive system is split into genitalia and
egg (oocyte), and the surrounding cells are called follicular
internal organs. The external genitalia are commonly
cells. As the egg within these cells grows and matures, the
referred to as the vulva and consist of:
follicular cells form more layers, called granulosa cells. As
• Labia majora the follicle grows bigger, these cells secrete oestrogen.3
• Labia minora
• Clitoris
• Vestibule The fallopian tubes
• Hymen
The fallopian tubes (oviducts) are approximately 10 cm
• Greater vestibular glands
(4 in.) long and extend laterally from the uterus.3 The tubes
The internal organs consist of (Figure 2.1): consist of two parts: the isthmus (short, narrow, thick-walled
• Two Ovaries portion nearer the uterus) and ampulla (wider, longer por-
• Two fallopian tubes (oviducts) tion of the tube, nearer the ovaries).3 From the ampulla of
Oviductal
infundibulum
Fimbriae
Ovary
Uterine corpus
Endometrium
Myometrium
Uterine isthmus Perimetrium
Internal cervical os Cervix
Cervical canal
Fornix
Vagina External cervical os
Coiled
Stratum artery
functionalis
Endometrium
Vein
Stratum
basalis
Myometrium
Perimetrium
(a)
Oviduct
Ovary Cervix
Uterus
Large bowel
Urinary bladder
Tail bone
Mons pubis
Clitoris
Urethra Anus
(b) Vagina
Figure 2.1 Female reproductive anatomy: (a) coronal plane; (b) sagital plane.
Reprinted from Jones R, Lopez K. The female reproductive system. In: Human Reproductive Biology, 3rd ed.; 2006. p. 31–72 [chapter 2];
with permission from Elsevier.
24
Anatomy and physiology of the reproductive system Chapter |2|
each ovary, there are finger-like projections called fimbriae, the bladder in front and the anus behind the vagina. Its
one of which (the biggest one) is attached to the ovary. anterior wall is 7.5 cm (3 in.) long, and the posterior wall
The main function of the fallopian tubes is to facilitate is 9 cm (3.5 in.) long. This is because the cervix (lower part
the transportation of the sperm to the egg and afterward of the uterus) protrudes onto the anterior side of the
to actively facilitate the passage of a fertilized egg into the vagina.2
uterus. The fallopian tube achieves this through a peristaltic A main function of the vagina is to act as a barrier to stop
and ciliary movement.2 The fallopian tubes also secrete microorganisms from entering the uterus. Lactobacillus aci-
mucus, thereby aiding the transportation of both sperm dophilus microbes are normally present in the vagina of
and egg. The fertilization of the egg usually happens in women of reproductive age. These microbes secrete lactic
the ampulla part of the fallopian tube. acid, which helps to maintain an acidic environment in
the vagina (pH 4.9–3.5). This acidic environment reduces
Uterus the chance of microorganisms surviving and entering the
uterus.2
The uterus (womb) is a pear-shaped organ, which lies antero-
posteriorly in the pelvis between the urinary bladder and the
rectum. The existence of the uterus was acknowledged by Abnormalities of the female
the ancient Egyptians in the papyrus writings from 2500 BCE.4 reproductive anatomy
The uterus is hollow and is approximately 7.5 cm (3 in.)
long and 5 cm (2 in.) wide, with walls 2.5 cm thick. The Ovarian factors
uterus has three parts:2 The ovarian follicles may fail to grow and release an egg. This
• The fundus: the upper part above the opening to the may be either temporary (for example, in women with
fallopian tubes, with two horns, one on each side of certain conditions such as Polycystic Ovary Syndrome or
fundus thyroid disease) or permanent (for example, in women with
• The body: the middle part Premature Ovarian Failure). Sometimes when an egg is
• The cervix: the lowest and narrowest point of the uterus, released, it may be of poor quality. The collapsed follicle
connecting the uterus and the vagina (known as the corpus luteum) that released the egg may
The uterine walls have three layers: perimetrium, myome- not function properly and may fail to produce adequate
trium, and endometrium. The thickness of the endometrium amounts of progesterone. The number of ovarian follicles
depends on the stage of the menstrual cycle. It is at its still available for ovulation (ovarian reserve) may be affected
thinnest just after the menstrual bleed (around 7 mm on by previous ovarian surgery, for example, where healthy
day 4),5 and it then gradually thickens to allow an embryo ovarian tissue is removed along with diseased tissue.
to implant (around 11 mm on ovulation day).5
After implantation, the main function of the uterus is to Tubal factors
provide the environment that nourishes and protects the
embryo.2 The fallopian tubal factor is another common cause of
If an egg is fertilized, it travels through the fallopian tubes subfertility.6 The fallopian tubes may be partially or
into the uterus, where it then attempts to implant into the completely blocked and unable to allow the passage of
uterine wall. If it succeeds, the foetus grows in the uterus sperm and egg. This is usually caused by a previous history
until approximately 40 weeks’ gestation, at which point of Pelvic Inflammatory Disease, infections, or endometri-
the baby will be born and the placenta expelled. osis. Some women with a history of ectopic pregnancy
During labour, the upper part of the uterus contracts may have had their tube(s) removed. For women with both
intermittently, while the cervix relaxes and dilates. As tubes missing or blocked, Assisted Reproduction Technol-
labour progresses, the contractions become more frequent, ogy (ART) treatment is the only way for them to conceive.
and the cervix keeps gradually dilating. Once it is fully Sometimes the fallopian tubes may be filled with fluid.
dilated (10 cm), the second stage of labour begins. This This is called hydrosalpinx. Fluid is believed to leak into
is when a woman helps to push her baby out. the uterus and be toxic to an embryo.6 In some women,
The cervix also produces mucus, which can act as a barrier hydrosalpinx necessitates the complete removal of the
to ascending infections. During the fertile window (around affected tubes.7
5–6 days before ovulation), rising oestrogen levels make
the cervical mucus less viscous. A thinner, less tenacious Uterine factors
mucus allows the sperm to enter the uterus more easily.
Congenital uterine abnormalities are found in 5.5% of the
female population, increasing to 8% of infertile women,
Vagina 13.3% of women with a history of miscarriages, and
The vagina is a tube that connects the vulva and the uterus. 24.5% of women with a combined history of infertility
It runs obliquely upward and backward at a 45 angle, with and miscarriages (Figure 2.2).8
25
Acupuncture for IVF and Assisted Reproduction
20%
15%
10%
5%
0%
Normal Infertile History of History of
population women miscarriages infertility and
miscarriages
a. Complete b. Partial
26
Anatomy and physiology of the reproductive system Chapter |2|
infertility/miscarriage history when compared to are contained inside the scrotum and suspended outside
normal population: 2.1% versus 0.3%, respectively). the body in front of the upper thighs and behind the
Other uterine abnormalities include problems with the penis. This ensures that the temperature inside the testes
endometrial lining not developing properly or certain is 2–3 C lower than the normal body temperature of
other uterine abnormalities that may impede implantation 37 C. This lower temperature is necessary for optimal
(for example, scarring from previous surgeries, fibroids, sperm production (spermatogenesis). Curiously, the left
polyps, or endometritis). testis is often suspended lower than the right one. If
Cervical problems include issues with the quality and the temperature gets too cold, the muscles in the testes
quantity of cervical mucus production. However, it is a rare can contract, and the testes will ascend inside the body
cause of subfertility.6 as very cold temperature is also not ideal for
spermatogenesis.10
The main function of the testicles is the production of
Male reproductive anatomy sperm and testosterone. Spermatozoa and nutrient fluid
The main functions of the male reproductive system are are produced by germ cells, which line the seminiferous
production and transportation of sperm. The male repro- tubules inside the testicles, and testosterone is produced
ductive system consists of (Figure 2.4): by the Leydig cells, which are located between the seminif-
erous tubules. There are hundreds of seminiferous
• Two testes
tubules inside each testis, each measuring 80 cm
• Two epididymides
(31 in.) long.10
• Two vas deferens (deferent or sperm ducts)
• Two seminal vesicles
• Two ejaculatory ducts Epididymides
• A prostate gland
The seminiferous tubules merge into the epididymides,
• A urethra
where spermatozoa mature and are stored. This maturation
• A penis
process takes 6 weeks. In the head of the epididymis, there
are 5–10 separate tubules, which merge into one tubule.
Testes This tubule is twisted and condensed, 5 cm (2 in.) in its
The testes (testicles) are two oval glands measuring 5 cm compressed form, and approximately 6 m (19 ft) long if
(2 in.) in length and 2.5 cm (1 in.) in diameter.2 They extended.10
Sigmoid colon
Bladder
Rectum
Pubic bone
Seminal vesicle
Suspensory ligament of penis
Ejaculatory duct
Puboprostatic ligament
Perineal membrane Prostate gland
External urethral sphincter Cowper’s gland
27
Acupuncture for IVF and Assisted Reproduction
28
Anatomy and physiology of the reproductive system Chapter |2|
Spermatogenesis Acrosome
Nucleus
Testis
Head
Spermatogonium
(46)
Basal body
Primary
spermatocyte Mitochondria
(46)
First
meiotic
division
Tail Axoneme
(23) (23)
Secondary spermatocytes
Second
meiotic
division
Endpiece
(23) (23) (23) (23)
Figure 2.6 Structure of a spermatozoon.
Spermatids Reprinted from Jones R, Lopez K. Gamete transport and fertilization. In:
Human Reproductive Biology, 3rd ed.; 2006. p. 231–52 [chapter 9];
Spermiogenesis
with permission from Elsevier.
29
Acupuncture for IVF and Assisted Reproduction
4,000,000
3,000,000
2,000,000
1,000,000
1,000,000
43,740 148,785
30
Anatomy and physiology of the reproductive system Chapter |2|
250,000
200,000
158,900
150,000
100,000
62,100
63,000
50,000
9600 1000
Zona pellucida
Nucleus
Egg cytoplasm
Corona radiata
(b)
Figure 2.10 Human egg: (a) a photograph; (b) human egg structure.
(a) Courtesy of Care Fertility, Nottingham, UK.
31
Acupuncture for IVF and Assisted Reproduction
Preovulatory
Early-antral
Secondary
Pre-antral
Primordial
Primary
Antral
Ovulation
Follicle category
Follicle class - - - Class 1 Class 2 Class 3 Class 4 Class 5 Class 6 Class 7 Class 8
Follicle diameter 0.03–0.06mm 0.06–0.12mm 0.12–0.2mm 0.2–0.4mm 0.4–0.9mm 0.9–2.0mm 2–5mm 6–10mm 10–16mm 16–20mm
Duration >150 days ~120 days 25 days 20 days 15 days 10 days 5 days 5 days 5 days 5 days
Hormones - Gonadotrophin responsive Gonadotrophin dependent (FSH) Higher levels of hormones (FSH, LH and
others)
Blood supply - Hormones and nutrients delivered via blood supply in follicles >0.08 mm
Figure 2.11 Follicular development in a human ovary with a conjectural overview of TCM influences.
Data from Gougeon 1986,24 Gougeon 1996,25 and Zeleznik 2004.26
32
Anatomy and physiology of the reproductive system Chapter |2|
changes occur in the ovaries. At the end of the luteal phase of Influence of acupuncture on late secondary
every menstrual cycle (days 23–28), several antral follicles to preovulatory follicles (approximately
are selected to continue developing. This is known as selec- 190–0 days before ovulation)
tion or recruitment of antral follicles (not to be confused with
recruitment of primordial follicles). Class 5 antral follicles Follicles bigger than 0.08 mm in diameter (secondary fol-
take around 20 days to develop to preovulatory class 8 folli- licles, around 190 days before ovulation) begin to respond
cles,24 and this phase is dependent on high levels of gonad- to their environment by acquiring arterioles. This allows
otrophins, in particular, FSH and LH.26 the delivery of reproductive hormones and nutrition to
Early in the follicular phase, one follicle is selected from a the follicles via these arterioles. Therefore, in addition to
pool of class 5 follicles (2–5 mm in diameter) to become Jing [Essence] and Yin, Blood and Qi influence the develop-
a dominant follicle.25 The dominant follicle grows very ment of follicles from this point on.
rapidly, reaching 6.9 mm on day 2, 13.3 mm on day 7, It is hypothesized that acupuncture may improve the
and 18.8 mm on day 12.31 quality of the follicles and the eggs within them by improv-
The rest of the follicles undergo atresia during both pre- ing the blood flow to the ovary.37 But the outcome depends
antral and antral phases, although follicles that are bigger on the duration of acupuncture treatment38 because it takes
than 2 mm in diameter are more commonly destined for about 1 year for the follicles to develop.24 The last 190 days
atresia and do not normally develop beyond medium stage are particularly important because that is when the follicles
class 6 follicles (maximum 10 mm in diameter).27 The begin to respond to their environment25 and therefore
development of follicles beginning during the early antral become even more likely to be influenced by acupuncture.
phase depends on FSH secretions. If FSH is absent, the During this phase of follicular development, acupuncture
follicles will stop developing.27 treatment should be aimed at tonifying Pre- and Post-Natal
During the downregulation phase of IVF, the levels of Jing (Essence), Yin, Blood, and Qi. In addition to the Jing
FSH are pharmacologically depleted, which temporarily (Essence) points listed above, use acupuncture points such as
stops the development of antral follicles, allowing a more BL17,34 ST36,39 SP6,40 KID6,33 LIV3,41 LIV8,41 and REN6.32
homogeneous group of follicles to be available during the
ovarian stimulation phase. During this phase, a woman
injects a large dose of FSH (usually into the abdomen), INTERESTING FACTS
which helps to rescue some of the class 5–6 antral follicles FOLLICLES AND FOLLICULOGENESIS
that otherwise would be destined for atresia.
Figure 2.11 summarizes all stages of follicular develop- ® The process of primordial follicle recruitment is
ment and suggests where TCM concepts and influences continuous. It starts in the foetus, continues after birth,
may be most usefully applied. and runs until the ovarian reserve is depleted.16
® Follicles up to 5 mm in size (class 5) are always present in
ovaries, from infancy to menopause. This is because
TCM integrated perspective on these follicles require only small amounts of
gonadotrophins. However, class 5 or bigger follicles are
follicular and egg development
dependent on larger quantities of hormones during the
Understanding Orthodox medical physiology of follicular 20 days preceding ovulation.25
and egg development aids in understanding TCM influences. ® In a small number of cycles, two follicles become
dominant, which may result in dizygotic
(nonidentical) twins.
Influence of acupuncture on primordial,
primary, and early secondary follicles
(approximately 360 and 190 days before
ovulation) REPRODUCTIVE PHYSIOLOGY FROM
AN ORTHODOX MEDICAL
The transition of primordial follicles to early secondary
follicles (around 360 to 190 days before ovulation) is PERSPECTIVE
independent from gonadotrophin and blood supply. The
follicles largely control their own growth and development The Hypothalamic–Pituitary–
during this period. Therefore, it is likely that primarily
Gonadal Axis
Pre-Natal Jing (Essence) influences this phase because a
woman is born with her complete ovarian reserve. It might The activity of the gonads (ovaries and testes) is controlled
be possible to influence this phase with acupuncture by by the hypothalamus and the pituitary glands.42 This is
nourishing Pre-Natal Jing (Essence). Acupuncture points referred to as the Hypothalamic–Pituitary–Gonadal Axis
REN4,32 KID3,33 BL23,34 BL52,34 GB39,35 and DU436 (HPGA), also known as the Hypothalamic–Pituitary–
tonify Jing (Essence). Ovarian Axis in women and the Hypothalamic–Pituitary–
33
Acupuncture for IVF and Assisted Reproduction
Testicular Axis in men. The HPGA is where reproductive Oestrogens, testosterone, and inhibins suppress the
hormones from the ovaries or testes, hypothalamus, and production of FSH, LH, and GnRH by the pituitary and
anterior pituitary gland exert control over circulating levels the hypothalamus.
of one another (Figure 2.12). The HPGA matures at
puberty, activating the cyclical development of antral fol-
licles and eggs, as well as the onset of ovulation and the INTERESTING FACTS
menstrual cycle.30 In men, HPGA maturation starts the
HYPOTHALAMUS IN REPRODUCTION
onset of sperm production.
The hypothalamus is situated between the midbrain and The emotional environment has a profound effect on the
the forebrain.43 It connects to the pituitary gland through reproductive process.42 The hypothalamus’ function is
the neural and vascular links by receiving neurohumoral influenced by signals it receives from other parts of the brain,
signals from other parts of the brain and the central ner- for example, the amygdala and hippocampus.43
vous system and hormonally derived messages from the
ovaries and the testes.43 The hypothalamus has many roles
in controlling reproductive functions, such as the onset of Key reproductive hormones
puberty, reproduction, pregnancy, and lactation.42,43
The hypothalamus releases GnRH in a pulsatile manner Gonadotrophin-Releasing Hormone
(at about 90–120 min intervals).43 GnRH is transmitted GnRH is released by the hypothalamus.3 It controls the sec-
through the portal vessels to the anterior pituitary.43 Here retion of FSH and LH both in the male and the female.3,42
GnRH binds to receptors of gonadotrophic cells in the pitu-
itary to affect the rate of the production and release of Follicle-Stimulating Hormone
gonadotrophin hormones (FSH and LH)43 and prolactin.42
In females, FSH stimulates the growth and maturation of
The anterior pituitary also secretes Growth Hormone (GH)
ovarian follicles.3
and Thyroid-Stimulating Hormone.42,43
In males, FSH stimulates sperm production.3
In women, FSH and LH stimulate the ovaries to grow and
mature follicles and eggs. The largest dominant follicle
starts to produce oestrogens and inhibins during the mid- Luteinizing Hormone
follicular phase.44 Oestrogens and inhibins suppress FSH In females, rising oestrogen levels cause LH to rise exponen-
production by the pituitary, which stops the development tially (peaking approximately 36 h before ovulation). This
of nondominant antral follicles, which then undergo atre- surge of LH triggers final maturation and the release of the
sia.44 In men, FSH and LH stimulate the testes to produce egg (ovulation). After the egg is released, the remainder of
sperm, testosterone, and inhibin. the follicle becomes luteinized under the influence of LH,
+
GnRH
Anterior pituitary
+
FSH and LH
- -
Oestradiol Testosterone
inhibin inhibin
Ovary Testicles
34
Anatomy and physiology of the reproductive system Chapter |2|
which stimulates the formation of progesterone in the fol- testosterone plays a role in sexual arousal.50 Low testoster-
licular granulosa and theca cells.43 LH also stimulates ovar- one levels are associated with low ovarian reserve.51
ian androgen production by the ovarian theca cells.45
In males, LH stimulates testes to produce testosterone
and inhibin.43
Inhibin
In the male, inhibin is secreted by Sertoli cells in the testes.
Oestrogens It inhibits spermatogenesis by inhibiting FSH secretions by
the anterior pituitary gland.3
In women, increasingly higher levels of oestrogens are In the female, inhibin is secreted by granulosa cells in a
secreted by the dominant follicle, resulting in increased growing follicle and by the corpus luteum.3 It controls FSH
GnRH secretions by the hypothalamus. This causes the ante- secretions43 and, to a lesser degree, LH secretions.3
rior pituitary gland to secrete higher levels of FSH and LH.3
This leads to the preovulatory LH surge, which triggers the
dominant follicle to release its egg during ovulation45; this Relaxin
occurs approximately 36 h later. In the beginning of the In women, a small amount of relaxin is secreted by the
menstrual cycle, oestrogen levels are low, thereby keeping corpus luteum to help with implantation by relaxing the
the GnRH, FSH, and LH levels relatively low.45 uterus.3 During pregnancy, more relaxin is produced by
In men, oestrogens are also secreted but in smaller the placenta.3
quantities.46 Oestrogen has an inhibitory effect on GnRH The role of relaxin in men is less clear. It is secreted by
release.47 prostate and is found in semen. It increases sperm motility
and sperm fertilizing capacity.52
Progesterone
In women, after ovulation, the corpus luteum (collapsed Other hormones
follicle) begins to secrete high levels of progesterone.45
There are other hormones that are involved in reproduc-
The levels of progesterone peak midway through the luteal
tion. These will be referred to and explained in this book
phase of the menstrual cycle. Progesterone, synergistically
where relevant.
with oestrogens, helps to prepare the endometrium for
implantation. High levels of progesterone also inhibit
production of GnRH and LH.3 Progesterone supports Menstrual cycle
embryonic development until the placenta takes over at
approximately 10–12 weeks’ gestation. The cycles of physiological changes that occur in women of
In men, progesterone regulates sperm capacitation and reproductive age are known as the menstrual cycles. Men-
motility and affects the receptors on the sperm’s acrosomal strual cycles are regulated through feedback of ovarian
membrane.48 hormones, GnRH, LH, and FSH.28
Typically the menstrual cycle length averages 2853–55 or
29 days.56 It can range from 2256 or 23 days55 up to 3555 or
Human Chorionic Gonadotrophin 3656 days in women from their early 20s to mid-30s.
In women, if implantation occurs and pregnancy follows, the Cycle lengths change with age. A large study involving the
trophoblast (implanting embryo) produces the Human measurement of thousands of cycles reported mean cycle
Chorionic Gonadotrophin (hCG) hormone, which keeps lengths to be 29 days in 18- to 20-year-old women, gradually
the corpus luteum producing progesterone and oestrogen reduced to 27 days by the age of 44, and then increased to
until 10–12 weeks’ gestation, by which stage the placenta 28 days in 45- to 47-year-olds, 32 days in 48- to 50-year-olds,
makes enough oestrogen and progesterone to support itself.45 and 39 days in 51- to 53-year-olds. There was very little cycle
In men, hCG stimulates testosterone production in the variability in the younger women, but in women 45 years or
testes.49 older cycle lengths varied considerably.57
Factors such as weight,58 physical activity,59 smoking,60
and psychosocial stress60 can affect cycle length.
Testosterone Long, irregular cycles with intermenstrual bleeding are
In men, the Leydig cells in the testes produce testosterone. associated with infertility.58 Long cycles double the risk
Testosterone controls spermatogenesis,43 whereby high of foetal loss.58
testosterone levels inhibit GnRH secretion by the hypothal- Menstrual cycles are split into two main phases: the follic-
amus. This causes the anterior pituitary gland to release less ular phase and the luteal phase. The follicular phase varies in
LH. Lower levels of LH lead to lower testosterone levels length (for example, 14 days in a 28-day cycle, 7 days in 21-
produced by the Leydig cells in the testes. During puberty, day cycle, and 19 days in a 33-day cycle), and the luteal phase
testosterone controls male sexual development.3 is usually fixed at around 14 days (Figure 2.13). Ovulation
Women also produce testosterone, but its reproductive marks the end of the follicular phase and the beginning of
role is not well understood although it is accepted that the luteal phase.
35
Acupuncture for IVF and Assisted Reproduction
36
Anatomy and physiology of the reproductive system Chapter |2|
37
Acupuncture for IVF and Assisted Reproduction
Female Male
Age 7 Abundant Kidney Jing (Essence) Age 8 Abundant Kidney Jing (Essence)
Kidney Qi is abundant, Tian Gui arrives Kidney Jing (Essence) is more abundant
Tian Gui arrives, sperm production is
Age 14 Ren Mai flows, Chong Mai in abundance Age 16
activated
Onset of menstruation and reproductive Arrival of male reproductive energy
energy
Age 21 Kidney Jing (Essence) has reached Age 24 Kidney Jing (Essence) reaches
a normal (adult) level a normal (adult) level
Age 28 Kidney Jing (Essence) has reached and Age 32 Kidney Jing (Essence) has reached and
remains at its highest level remains at its highest level
Tian Gui initiates menarche and reproductive potential Qi, Blood, and Jing (Essence)
in the female. At the age of 14, Tian Gui arrives.72 The
Ren Mai (Conception Vessel) is activated and flows, and Qi
the Chong Mai (Penetrating Vessel) is abundant and men- There is no word in the English language that translates
ses occurs harmoniously. This is the onset of reproductive and encompasses the meaning of Qi. Qi is described as
potential in a female. breath that occurs through transformation, ‘an exhala-
A woman is most fertile in her 20s. Blood is the precursor tion and releasing movement’.75 Taoism provided the
to reproductive decline in the female. At the age of 35, a conceptual framework for TCM. Concepts of Qi are
woman’s Blood decreases and fertility declines. At the age therefore strongly related to Taoism. Qi is everywhere;
of 42 to 49, the Ren Mai (Conception Vessel) and the Qi gives life to all things. In a human being, Qi is ‘pro-
Chong Mai (Penetrating Vessel) begin to weaken and even- foundly interactive in the body’,76 and it interacts with
tually become Deficient, Tian Gui is drained,72 and a vital substances (for example, Jing (Essence) and Blood)
woman is almost infertile. and the external environment77 (for example, the
In the male, at the age of 16, Kidney Qi thrives and Tian seasons).76
Gui arrives, which indicates the beginning of his reproduc- As with other aspects of TCM, Qi is not a physical matter
tive potential.72 The Kidney is the precursor to reproductive that can be measured or investigated in the laboratory
decline in the male.71 At 40 years of age, male reproductive setting.
ability declines, marked by a weakening of Kidney Jing In traditional and contemporary TCM practice, Qi is
(Essence). At 48 to 56 years of age, a man’s Kidney Yang understood through its context, type, and function and by
becomes exhausted, Tian Gui is depleted, sperm is scant, the assessment of health and illness. For example, one of
and the Kidneys become weak.72 Figure 2.15 summarizes the functions of Qi is to facilitate circulation. If this function
reproductive ageing from the TCM point of view. fails, Qi is said to be Stagnant.
38
Anatomy and physiology of the reproductive system Chapter |2|
The main functions of Qi are: circulatory system. Blood is a material form of Qi.85 Blood
78
• Powering function: Qi stimulates and completes and Qi represent a Yin Yang pair, Blood being more Yin and
growth, development, activity, circulation, and Qi being more Yang.87 In TCM, Blood is essential for life
distribution.79 For example, Qi aids in the creation and and is central to reproductive health. It delivers nutrients
the development of an embryo. to the body.79,87 Blood and Qi determine initiation and
• Warming function:78 Qi, in particular Yang Qi, function of menstruation and conception.88,89
produces heat to keep the body warm. In reproduction, The Stomach transforms food and drink into Gu (Food)
Qi helps to warm the Uterus and maintain an Qi, which is referred to as [Post-Natal] Jing (Essence).83 The
appropriate environment for the embryo. Stomach transforms and distributes Unclear Gu (Food) Qi
• Protecting function:78 Qi acts as a defensive boundary to the Heart.90,91 After Blood has passed through the
and protects the body from the external environment. Heart,86 it turns red.92 The Spleen sends Clear Gu (Food)
Wei (Defensive) Qi helps to prevent EPFs from entering Qi to the Lung where it combines with [Air] Qi.86,90,91
the body.80 For example, it prevents External Wind- The Lung propels it to the Heart.85 Zong (Chest) Qi assists
Cold from invading the body. the circulation of Qi and Blood.82 The Stomach also dis-
• Holding function:78 Qi holds and supports a form, tributes Gu (Food) Qi [Essence] directly to the Liver, and
shape, and position. For example, Qi helps to hold the this form of Jing (Essence) is stored as [Liver] Blood.90,91
foetus in the Uterus and the Blood in the Vessels. Figure 2.16 summarizes the main steps in Qi and Blood
• Transforming function:78 Qi facilitates transformation production.
from one form to another. For example, in the Interestingly, Maciocia states that Yuan (Original) Qi
menstrual cycle Qi facilitates transformation from Yin and Bone Marrow, which is generated by Kidney Jing
into Yang and vice versa. Transformation creates the (Essence), are involved in the production of Blood and that
embryo. The transformation of Qi generates the five Blood is produced by Bone Marrow.85 Other authors state
emotions: Joy, Anger, Sadness, Anxiety, and Fear.81 that Bone Marrow does not produce Blood, but instead
Kidney Yin nourishes Liver Blood,94,95 which, according
Qi is categorized according to its functions in the body. The
to other authors, is why Liver Blood is synergistic in presen-
main types of Qi are:
tation and ability with Kidney Jing (Essence).86 The rela-
• Zheng (Right or Correct) Qi: facilitates harmony in tionship of mutual engenderment and balance between
the body by being ‘present in the correct place at the the Kidney and Liver is where the saying that the Liver
correct time’. It rectifies incorrect functions of Qi to and Kidney share the same source comes from.96
prevent illness.82 Zheng Qi is opposite to disease- The functions of Blood include:
causing or pathogenic Qi.
• Circulating around the body83
• Zong (Gathering or Chest) Qi: combination of
• Nourishing and moistening the tissues79,83
different types of Qi,82 stored in the chest.79 It is a
familial hereditary Qi, which is responsible for
• Being the basis for mental activity79 and clarity83 of
Shen (Mind)
producing, consuming, and the circulation of Qi and
Blood.82,83
• Governing the woman. Blood is a sign of procreative
and generative power97
• Yuan (Original) Qi: Qi potential, which is Qi before it
• Creating and nourishing life, including the embryo and
is expressed in ‘specific forms’.82 The original supply of
the foetus
Yang and Yin83 provided by parents. Jing (Essence)
assists in the functions of Yuan (Original) Qi83 and acts Blood is influenced by the environment, for example, the
as a catalyst in the formation of Zhen Qi and Blood. waxing and waning of the moon.98 EPFs and internal dys-
• Zhen (True) Qi: represents the laws of nature.83,84 function also influence Blood.68,97 Lifestyle and diet affect
• Gu (Food or Grain) Qi: produces Jing (Essence) and Blood quality and quantity.68 In ill health, Blood can
Blood; together, they nourish the body.81 become Deficient and/or Stagnant, Hot or Cold, and this
• Wei (Defensive) Qi: circulates, defends,80 protects, can contribute to subfertility.68
and nourishes the body.79,85 Blood is closely related to Qi, Jing (Essence), and Body
• Ying (Nutritive) Qi: nourishes, rebuilds, and Fluids; these relationships are outlined in Figure 2.17.
maintains the whole body, including channels and
Zangfu organs; activated by acupuncture.82,85
39
Acupuncture for IVF and Assisted Reproduction
Unclear Gu (Food) Qi
Clear Gu (Food) Qi
Zong (Chest) Qi
Spleen
Gu(Food) Qi Essence
Gu(Food) Qi
Liver Essence Stomach
Food Kidney
and
drink Yuan (Original) Qi
Nourishes Produces
Nourishes
Jing (Essence)
There are two types of Jing (Essence): Pre-Natal and Post- responsible for the flourishing of Pre-Natal Jing (Essence).
Natal.79,101 Pre-Natal Jing (Essence) is the energy passed to Yuan Qi is the functional manifestation of Pre-Natal Jing
an embryo by its parents. The Kidney stores and releases (Essence).101
Pre-Natal Jing (Essence),102,103 and this function is gov- Food and water transform into Post-Natal Jing (Essence)
erned by Yuan (Original) Qi.101 Yuan (Original) Qi is and nourish Pre-Natal Jing (Essence).85,100,101,104
40
Anatomy and physiology of the reproductive system Chapter |2|
Jing (Essence) characteristics include:81 If this hypothesis is correct, then in women with ovarian
• Being a source of life74 reserve issues or history of poor follicular development, acu-
• Transforming Qi81 and transforming into Qi puncturists need to examine which of these key components
• Determining life cycles: growth, reproduction, and are suboptimal and address this in their treatment plan. For
development85 example, if present, Blood Deficiency may be associated
• Circulating around the body79 with the Liver, the Heart, or both. Yin Deficiency may
• Determining an individual’s constitution85 involve the Kidney and/or the Liver and/or the Stomach.
• Controlling sexual desire101 Pathogenic Factors may be blocking Jing (Essence), Blood,
• Manifesting as Heavenly Water (menstruation),101 Qi, or Yin or may damage Yin or Qi. Pre-Natal Jing (Essence)
sperm,100 and eggs may be linked to women with a lower-than-expected ovar-
• Controlling the health101 and development of ian reserve for their age. Where women have good ovarian
the embryo reserve but produce low numbers of or low-quality eggs,
• Pre- and Post-Natal Jing (Essences) and Qi are the Post-Natal Jing (Essence) and/or Qi may be implicated.
material basis for Shen (Spirit)105 Figure 2.18 summarizes our interpretation of the mature
egg from a contemporary integrated TCM point of view.
For conception, both Kidney Jing (Essence) and Yuan
(Original) Qi need to be healthy.101 Weak Jing (Essence),
Blood, Qi,68 and Bodily Fluids cause infertility, poor egg
and sperm quality and quantity, or difficulty in forming Sperm
the embryo.101
In the classical TCM literature, semen is associated with Jing
(Essence).68,106,109 In contemporary TCM literature, sperm
Egg is said to be Kidney Jing (Essence)110 or Tian Gui.73
In classical TCM literature, an embryo was thought to be With the current medical knowledge of male reproduc-
formed from male Kidney Jing (Essence) and female tive physiology, the explanation of what sperm is can be
Blood.106 In contemporary TCM literature, very few refer- developed further:
ences exist that explain what eggs are. Some authors suggest
that eggs are Jing (Essence)107,108 or Tian Gui.73
In our opinion, it is too simplistic to say that eggs are Jing
(Essence) or Tian Gui. In our understanding and interpre-
tation of classical TCM female physiology, we hypothesize
Blood, Yin,
that eggs are made and influenced by several additional key
Qi, Post-
components: Natal Jing
Tian Gui
• We know that a female foetus has all the eggs she is
going to have for her entire reproductive lifespan. So we
can confidently suggest that this supply of eggs is
equivalent to Pre-Natal Jing (Essence) that is passed to
Pre-Natal
the female foetus by her parents. Jing
• At the age of 14, when the Kidney Jing (Essence) is
abundant, Tian Gui arrives (as described earlier in this
chapter), and the woman’s reproductive life
commences. We can equate this to the activation of the
Hypothalamic–Pituitary–Ovarian Axis (HPOA), which
regulates reproductive function in women. Thus, eggs
will not continue developing unless there is a correct
hormonal balance, which is provided by activation of
the HPOA. (This equates to additional influences from
a TCM perspective.)
• From the Orthodox medical point of view, it is well
documented that follicles require a good blood supply
in order to continue developing. Therefore, we
hypothesize that from TCM point of view, a woman’s
eggs depend on good supply and circulation of Blood,
Yin, Qi, and Post-Natal Jing (Essence).
Mature egg
There may also be other important influences. We hypoth-
esize that the ones listed above are the most significant ones. Figure 2.18 Integrated interpretation of what a mature egg is.
41
Acupuncture for IVF and Assisted Reproduction
Menstrual cycle
The menstrual cycle (metaphorically referred to in TCM lit-
erature as the ‘monthly affair’) is considered regular if it
occurs every 28–30 days.72 In medieval times, Sun Simiao
Yang, Yin, acknowledged the role of the menstrual cycle in female
Qi, Post- health and fertility.68,112 Sun Simiao described irregular
Tian Gui Natal Jing menstruation as menses that did not occur monthly.68,112
In the classical TCM literature, menses was considered
irregular if it occurred early or was delayed.68,88,112
The assessment of menses included the flow, consistency,
Pre-Natal and the amount of Blood lost.88,113 The flow of menses is
Jing central to fertility. For example, stop–starting or spotting
is considered abnormal68,112 because this illustrates
pathology of Blood, Qi, and Bodily Fluids.
Examination of the colour of menses (according to the
five-phase system of correspondence) was also relevant.68,112
Broader manifestations in relation to the menstrual
cycle included the role of emotions in female health and
tiredness.68,112
Fu Qing-zhu and Sun Simiao described manifestations
of abnormal menstruation to include symptoms such as
menstrual pain.68,88,112 Pain could occur in the abdomen
or legs.68,112
The menstrual cycle is regulated by Kidney Jing (Essence),
Tian Gui (Heavenly Water), Yin and Yang, Blood, Qi, the
Zangfu organs, the Extraordinary Vessels, and Fu.
Fu Shan stated that menstrual flow originates from the
Mature sperm Kidneys and that ‘freeing Essence’ is one among several
ways to regulate the menstrual cycle.88 He discussed how
Figure 2.19 Integrated interpretation of what mature sperm is. Liver Qi Stagnation blocks the flow of Kidney Qi and thus
42
Anatomy and physiology of the reproductive system Chapter |2|
Bao
Mai
Stomach
Liver Chong and Ren Mai
Spleen
Qi, Blood, Yin
Qi, Blood, Jing
Uterus
Heavenly Water (Menses)
Bao
Luo
Kidney Lung
Jing, Tian Gui Qi
affects the time of arrival of the menses, with irregular Yang decreases, while in the second half Yang increases and
cycles leading to difficulty conceiving.88 Yin decreases. Ovulation marks a rapid change from Yin to
More recently, Liu Feng Wu (1976) described menstrual Yang (i.e. Yang increases and Yin decreases), while
irregularities as ‘a manifestation of dysfunction of the inte- menstruation marks a rapid change from Yang to Yin
grated function of the body’.114 He related nonstandard (i.e., Yang decreases and Yin starts to increase)’.116
variations of a menstrual cycle to dysfunction of the
Zangfu organs, particularly the Kidney, Liver, and Spleen. However, Guicheng did not make any attempts to equate
Liu Feng Wu stated that menstrual disease results from loss Yin Yang with a typical pattern of reproductive hormone
of regulation of the Kidneys, Qi, Blood, and Extraordinary level.116 The functions of Yin and Yang in the menstrual
Vessels, in particular, the Chong (Penetrating) and Ren cycle allow us to draw some comparisons between the hor-
(Conception) Mai. He concluded that the treatment of mones and Yin Yang. FSH, oestrogen, and LH dominate the
Blood disharmony should be the primary method of reg- first half of the cycle (follicular phase),117 and they are at
ulating menstrual cycles. Liu Feng Wu drew an analogy their highest just before ovulation,117 which according to
between the regulation of the menstrual cycle and the Guicheng is when Yin peaks. Progesterone is highest in
regulation of hormones.114 the second half of the cycle (luteal phase),117 and this
phase is under the influence of Yang. Oestrogen peaks at
ovulation time, then rapidly declines and rises again a
The four phases of the menstrual cycle few days later.117 Therefore, oestrogen is under the influ-
ence of both Yin and, to a lesser degree, Yang.
and Yin Yang
Table 2.1 summarizes the complex interactions between
Chinese philosophers view the world in terms of natural the key reproductive hormones, Yin Yang, and follicular
laws that govern life. These principles include Yin Yang the- and endometrial development; it also provides a summary
ory.115 In the 1960s, Xia Guicheng developed the four-phase of key events from Orthodox medical and TCM points of
menstrual cycle model based on Yin Yang principles:116 view. Chapter 8 discusses menstrual cycle regulation with
acupuncture.
‘The four phases of the menstrual cycle illustrates physiology Yin and Yang are closely related121 to the menstrual
and pathology corresponding to the ebb and flow of Yin and cycle. The harmonious relationship of Yin and Yang is
Yang. During the first half of the cycle Yin increases and essential for a healthy menstrual cycle:
43
Acupuncture for IVF and Assisted Reproduction
Table 2.1 The menstrual cycle: Key reproductive hormones, Yin Yang, follicular and endometrial development,
TCM and Orthodox medical menstrual cycle activity (day 0 ¼ ovulation day)116,117
Yin
Yang
LH
Progesterone
FSH
Oestradiol
44
Anatomy and physiology of the reproductive system Chapter |2|
Table 2.1 The menstrual cycle: Key reproductive hormones, Yin Yang, follicular and endometrial development,
TCM and Orthodox medical menstrual cycle activity (day 0 ¼ ovulation day)—cont’d
TCM physiology
Yang at its peak begins to Blood and Yin are relatively empty, Blood and Yin Yang rises and Liver Qi
decline. Yin is born. Chong Mai the Ren and Chong Mai gradually fill the moves in preparation for
empties. Blood develops118 are depleted119 Chong, Ren, and Du the period119
Free flow of Liver Qi aids Blood Kidney Yin starts to grow120 Mai119 If a woman is not pregnant,
movement119 Before ovulation, Yin peaks, the The action of the 1118 to 3120 days before
Chong Mai is full of Blood118 Heart via Bao Mai menstruation, Yin and
facilitates Yang become insufficient
ovulation118
As ovulation occurs,
Kidney Yin
transforms into
Kidney Yang120
• The opposition of Yin Yang: occurs during the system is discussed in this chapter with an emphasis on fer-
menstrual cycle, for example, when comparing the Yin tility and early pregnancy. Where possible, links are drawn
phase to the Yang phase and vice versa. Also, there is between the essential functions of Zang organs and key
always an element of Yin in Yang and Yang in Yin. aspects of reproductive physiology related to the treatment
• The interdependence of Yin and Yang: one phase and management of subfertile patients and patients
of the menstrual cycle does not exist without the undergoing ART.
other; the Yin phase is caused by the Yang phase, and
the Yang phase is dependent on the Yin phase.
• Mutual consumption of Yin and Yang: the Yang phase The Kidney
is a product of Yin (for example, the luteal (Yang) Achieving a pregnancy and live birth is strongly linked,
phase is only possible if the ovarian follicle grows though not limited to, healthy functioning Kidneys. The
during the follicular (Yin) phase). Kidney influences the functions of all the other Zangfu
• The intertransformation of Yin and Yang: ovulation organs. The Kidney’s reproductive functions are closely
marks the intratransformation of Yin into Yang, and, if related to Mingmen (the Gate of Life).125,126
no pregnancy occurs, mutual consumption generates There are several records regarding the location of Ming-
another menstrual cycle, and Yang transforms back men (the Gate of Life).126 One view is that the space
into Yin with the onset of menses. between the Kidneys is Mingmen (the Gate of
Assessing the menstrual cycle according to the natural Life).81,125,126 Another view is that the right Kidney is Ming-
affinity of Yin and Yang provides key information about men (the Gate of Life).66,125–127 Thus, the term Mingmen
a patient’s reproductive physiology and well-being. (Gate of Life) either signifies the Fire existing between
Figure 2.21 summarizes the key Yin Yang relationships the Kidneys125 or refers to the right side where there is
in a menstrual cycle. Mingmen (Gate of Life).
Nanjing 36 states, ‘The Gate of Life is where Essence-
Spirit (Jing-Shen) is stored and Yuan (Original) Qi is
Key Zangfu organs in fertility enclosed’.127 In a male, the Gate of Life is connected to
and early pregnancy the Chamber of Semen, which stores sperm. In a female,
Zang are solid organs, and they are Yin. Fu are hollow the Gate of Life is connected to the Uterus (Figure 2.22).66
organs, and they are Yang.99 The Fu organs process liquids The basic functions of the Kidney are:
and food and spread Body Fluids.122,123 The Zang organs • The Kidney stores128,129 and provides Pre-Natal Jing
combine with Fu organs, and all organs are linked to cor- (Essence) and Yuan (Original) Qi81,127 for
responding meridians.124 Shen (Spirit), Jing (Essence), reproduction, development, and growth.89
Qi, and Blood circulate through the body to nourish and • Kidney Jing (Essence) is the origin for the formation of
maintain life.122,123 The five Zang organs are reservoirs of Tian Gui (Heavenly Water), which influences
these.124 The key Zangfu organs for fertility are the Kidney, reproduction.119 It is formed under the influence and
Liver, Heart, Stomach, Spleen, and Lung. abundance of Kidney Qi.119
Zangfu organs are interconnected and interrelated with • The Kidney governs sperm, menstruation (including
each other in physiology and pathology. The Zang organ the opening and closing function101 of the genitals),
45
Acupuncture for IVF and Assisted Reproduction
Day 1 menses
Intra transformation
tual consumption
Mu
pendenc
erde e
Int
Opposition
Follicu
Yang phase of
Luteal phase
menstrual
Progesterone cycle Oestrogen
lar phase
Yin phase of
menstrual
cycle
Opposition
In t
erd ependence
Mu
tu al c on
o n s u m p ti
Intra transformation
Ovulation
Figure 2.21 Taiji symbol: Yin Yang relationship in the menstrual cycle.
conception, and the embryo and foetus through Pre- (Essence) and affects the quality and firmness of it, an
Natal Jing (Essence), Qi, and Blood. important function implicated in the quality of an embryo.
• The Kidney connects to the Uterus89 through the Bao Luo Kidney Qi is responsible for governing menstruation and
(Uterine Channel), providing the Uterus with Jing pregnancy through its opening, releasing, and closing func-
(Essence) to nourish follicles and eggs, for menstruation, tions. Kidney Qi ensures that Pre-Natal Jing (Essence),
conception, and nurturing the embryo and foetus.89 Blood, and Fluids are released properly as menses.101
• The Kidney sustains the quality and function of all The Kidney is equally important for male fertility. Pre-
other Zangfu organs.128 Natal Jing (Essence), also referred to as Tian Gui, is a source
• It fills the bones with Pre-Natal Jing (Essence), of sperm.73 The sperm duct and semen are governed and
generates Marrow,95,124,130 and fills the Brain with controlled by Kidney Jing (Essence) and Kidney Qi through
Jing (Essence). the storing, releasing, and closing functions.133 Semen is
• It enriches and nourishes the Liver by providing it with strongly allied with Pre-Natal Jing (Essence) and Qi.74
Kidney Yin.94 A reduction in Kidney Jing (Essence), Yin Yang, or anything
• The Kidney supports the flow of Yin in the Ren Mai blocking or preventing it (for example, Stagnation, Damp-
(Conception Vessel) and supplements Blood in the ness, or Phlegm) can lead to male subfertility.
Chong Mai (Penetrating Vessel).131 The Kidney is also responsible for the viability and
Female fertility depends on the abundance of Blood, Qi, proper development of an embryo. The foetus’s survival
and Jing (Essence).132 The Kidney provides Jing (Essence); depends on maternal and paternal Jing (Essence) from
therefore, it can be thought of as the fundamental basis of the Kidney.84,134 The mother nurtures her embryo through
fertility. It provides the foundation for Pre-Natal Jing all its stages of growth and development.134
46
Anatomy and physiology of the reproductive system Chapter |2|
Gate of Gate of
Kidney Kidney
Life Life
Chamber of
Uterus
Semen
Reproductive failure is strongly linked with Kidney Jing In extreme cases, Kidney Jing (Essence) Deficiency may
(Essence) Deficiency.72 Eggs and sperm are related to lead to complete sterility, where no eggs or sperm are pro-
Pre-Natal Jing (Essence) and Kidney Yin and Yang. Any duced and donor eggs or sperm are required in order to
problems with eggs and sperm can be a direct result of conceive. Kidney pathology is associated with infertility
any Kidney pathology. issues such as age-related decline in fertility, poor follicular
Kidney Deficiency is associated with reduced ovarian response to IVF medication, cancelled IVF cycles, repeated
reserve. The ovarian reserve is often lower in older women IVF failures, and miscarriage(s).
or in women with Kidney Jing (Essence) Deficiency. During Figure 2.23 summarizes the complex interactions and
IVF, even if several eggs are collected, their quality and the reproductive functions of the Kidney and all key Zangfu
quality of any resulting embryos may be compromised. organs.
This is why IVF pregnancy rates are lower in older women.
The quality of the egg is also strongly linked with the
The Liver
quality of Yin and/or Blood. There is a strong relationship
between the Kidney and Zangfu organs involved with Although the Kidney is the basis for reproduction, the Liver
Blood. For example, a Deficiency of Kidney Yin may lead allows conception to occur.
to Deficiency of Liver Blood and, therefore, poor quality
eggs and embryos. Or Stomach and Spleen Qi Deficiency ‘It is due to her Liver that Blood is able to make life’.132
may reduce Post-Natal Jing (Essence), and this, in turn,
may influence Blood and Pre-Natal Jing (Essence). The basic functions of the Liver are:
47
Acupuncture for IVF and Assisted Reproduction
Du Mai
Heart
Bao Mai
Du Mai
Kidney Lungs
Bao Luo
Stores, governs, and
provides Pre-Natal Jing Root of Qi and
(Essence) circulation
Figure 2.23 The relationships among key Zangfu organs, the Extraordinary Vessels, and the Uterus in reproduction.
• Storing, generating, and regulating Blood128 and In our opinion, pathology of the Liver is strongly linked
Qi.128,129,135 to menstrual cycle irregularities, infertility, implantation
• Releasing Blood for menses.89,132 and IVF failure, and early miscarriages.
• Taking charge of the eyes.66,95 In our experience, issues with ovarian reserve can result
The Liver generates the energy of Blood and stores Blood; from Kidney Jing (Essence) Deficiency and/or Liver Blood
this is responsible for correct movement and circulation Deficiency. A history of problems with the endometrium
of Blood in the body132 and the regulation of menses. during IVF can result from Kidney Jing (Essence) and Yin
and Liver Blood Deficiency. Follicular recruitment and
‘It is the movement of the Liver on the Yin side storing the development is connected to the Liver’s function of generat-
Blood, and on the Yang side giving the impulse for all ing and regulating Blood as well as the Liver’s, Kidney’s, and
circulation, sending forth and spreading out, Yin is the Heart’s interrelationship with each other and the Uterus.
basis for Yang’.132 Figure 2.23 summarizes the complex interactions and re-
productive functions of the Liver and all key Zangfu organs.
The Liver regulates the menstrual cycle by moving Qi and
Blood.132 A healthy menstrual cycle promotes fertility The Heart
and optimizes a woman’s response to IVF treatment.
The Liver and Kidney both help to facilitate implantation The Heart is the centre of fertility. It promotes Blood circu-
and pregnancy, particularly in the early stages. The first lation to the Uterus. The basic functions of the Heart are:
month of pregnancy is when Jing (Essences) concentrate, • Generating92,128 and controlling changing128 of Shen
Blood coagulates, and the embryo ‘knots’.84 (Spirit)
48
Anatomy and physiology of the reproductive system Chapter |2|
• Connecting to the Uterus through the Bao Mai (Uterine and Qi131 for menstruation. The Stomach also enriches
Vessel) Yin, thus helping the Ren Mai (Conception Vessel).142
• Mastering Blood,66 promoting Blood circulation,66,95 Figure 2.23 summarizes the complex interactions and
directing Blood to the Uterus,89 and filling up Blood reproductive functions of the Stomach and all key Zangfu
vessels136 in the Uterus organs.
• Enabling menstruation, conception, and pregnancy89
• Manifesting in the complexion137
The Heart and the Mind of a woman should be harmonized The Spleen
throughout menstruation, fertility, conception, and The basic functions of the Spleen are:
pregnancy.84
• Forming Blood86
• Keeping Blood in the correct place89
‘Human life is brought about in the Essences and both
• Supporting the Chong (Penetrating) Mai in regulating
Essences are drawn together in Spirit’.128 menstruation by supplementing Blood and Jing
[Essence]131 through Qi
The Heart generates and stores Spirit. The terms Shen and • Enriching Kidney Yin and Yang through Qi and
Spirit are often used synonymously.138 Shen (Spirit) is Blood143
acquired when the Body, Heart, and Mind are settled, calm, • Nourishing the body and aiding regeneration of Bodily
and ‘properly aligned’.139 Shen (Spirit) promotes move- Fluids (together with Stomach and Kidney)144,145
ment and vitality of Jing (Essence), Qi, and Blood by invig- • Lifting and securing the Uterus89
orating and circulating them around the body. • Nurturing the embryo132,134
Yin, Blood, and Qi support fertility and conception. Copi-
‘Suppression of menstruation is due to a blockage of
ous Blood is essential for conception.119 The Spleen sup-
meridian within the womb, which belongs to the Heart
ports fertility by forming Qi and Blood, while the Heart
and is linked with the internal region of the womb’.140
masters Blood. Qi and Blood can transform into Post-Natal
Jing (Essence), and Jing [Essence], in turn, can transform
Follicular growth and egg maturation depend on Blood cir- into Blood.
culation and the Heart’s function of directing Blood to the The Spleen is affiliated with the Uterus via the Chong
Uterus. Weakness of this function will compromise fertil- (Penetrating) and the Ren (Conception) Mai.89 The abun-
ity, follicular development during IVF, and conception. dance of Stomach and Spleen Blood and Qi ensures nutri-
Figure 2.23 summarizes the complex interactions and tional enrichment and renewal of Blood to support the
reproductive functions of all key Zangfu organs. Chong Mai.142
By delivering Qi, Blood, and Jing (Essence) to the
The Stomach embryo via the Chong and Ren Mai, the Spleen (together
with the Stomach) provides essential nutrients to the
The basic functions of the Stomach are:
embryo in order for it to survive.132,134
• Generating Qi and Blood119,129,136 and Post-Natal Jing During IVF, if Spleen Qi and/or Blood is Deficient, the
(Essence) embryo may fail to implant, or, if it implants, it may stop
• Transforming and distributing Gu (Food) Qi141 to the developing, and the pregnancy will fail.
Heart and the Spleen, which in turn transforms and Figure 2.23 summarizes the complex interactions and
distributes128 Gu (Food) Qi and Post-Natal Jing reproductive functions of the Spleen and all key Zangfu
(Essence)86 into Qi and Blood for reproductive organs.
purposes
• Supporting, and facilitating the Chong Mai’s
(Penetrating Vessel) role of regulating menstruation by The Lung
supplementing Blood and Jing (Essence)131
The basic functions of the Lung are:
Jing (Essence) consists of Pre- and Post-Natal components.
The Stomach (together with the Spleen) supports fertility as • Generating Qi,136 Blood,83 Jing (Essence), and Bodily
it is the source of Post-Natal Jing (Essence), Qi, and Blood. Fluids, which are all essential for menstruation,
Post-Natal Jing (Essence) nourishes, rebuilds, and main- conception, and pregnancy146
tains the body.83 Diet is important in the reproductive field • Governing Qi66 and regulating rhythms of the Zangfu146
because the Stomach’s ability to produce Post-Natal Jing • Filling up the skin with Lung energy130 and defending
(Essence) depends on good dietary habits. Post-Natal the body from EPF invasion66
Jing (Essence) nourishes Pre-Natal Jing (Essence). The Lung is situated near the Heart. Its physiological and
The Stomach links with the Chong (Penetrating) Vessel, anatomical connection closely assists the Heart in its repro-
strengthening the Sea of Blood by providing Jing (Essence) ductive functions.
49
Acupuncture for IVF and Assisted Reproduction
The Lung is the root of Qi. It provides a balance of Qi146 and is joined also to the Kidney. The Bao Mai (Uterine Ves-
and supports the functions of Qi within the body and the sel) links the Uterus and Heart. The Bao Mai is an impor-
Zangfu organ system. It governs breathing and regulates tant connection that links the Shen (Spirit/Mind) of the
essential rhythms of the Zangfu organs, which assists fertility. female to the Uterus. The Bao Mai enables circulation
The Lung assists fertility by circulating Qi, Jing and regulates the distribution of Blood to the ovaries and
(Essence),101 Blood, and Bodily Fluids around the body.101 Uterus. During conception and pregnancy, this network
These substances are also the foundation for menstruation nourishes and protects the embryo.148 The Bao Luo (Uter-
and nourishment of the embryo.89 ine Channel) links the Uterus and Kidney in order to pro-
Weakness of the Lung leads to poor generation of Qi, vide Pre-Natal Jing (Essence).148
along with poor circulation of Qi and Blood, which com- Figure 2.23 summarizes the complex interactions and
promises fertility. reproductive functions of the Uterus and all key Zangfu
Figure 2.23 summarizes the complex interactions and organs.
reproductive functions of the Lung and all key Zangfu
organs.
Zangfu organ interactions and IVF
During the stimulation phase of an IVF treatment cycle, the
The Uterus Heart, Kidney, and Liver (and Extraordinary Vessels) regu-
The basic functions of the Uterus are: late the ovaries, thus facilitating follicular growth, egg mat-
uration, and the endometrial lining. The Uterus also
• Regulating menstruation,147 conception, and
pregnancy147 receives Qi, Blood, and Jing (Essence) from other Zangfu
Gathering Blood and Qi from all Zang organs148 organs, in particular, the Stomach and Spleen.
•
In IVF, the embryo is transferred into the Uterus. The
• Receiving Pre-Natal Jing (Essence) from the Kidney and
Post-Natal Jing (Essence) from the Stomach and embryo continues to develop and grow in the Uterus with
Spleen149 via the Chong Mai (Penetrating Vessel) the aid of the Extraordinary Vessels and Zangfu and under
Storing Jing (Essence) and Blood for menstruation149 the influence of Jing (Essence), Shen (Spirit), Qi, and
•
Blood. The embryo also develops through its own embry-
• Retaining and releasing the egg(s)
onic Qi (see Chapter 3).
• Retaining sperm after intercourse or artificial
insemination
• Accepting, holding, and protecting the embryo and
foetus148 and facilitating the embryo’s health, The key Extraordinary Vessels
nutrition, and development in reproduction
Influenced by the Extraordinary Vessels and Zangfu organs,
The Zangfu organs and Extraordinary Vessels regulate the
the Uterus allows the entire TCM reproductive physiology
menstrual cycle. They are referred to as reservoirs because
system to interact and bring new life into the world.
they regulate the amount and flow of Qi, Blood, and Jing
The Uterus is an Extraordinary Fu organ150 because it
(Essence) during the menstrual cycle. The Extraordinary
transforms, transmits,151 and releases Heavenly Water
Vessels strengthen meridians by circulating and distribut-
(menses).
ing Yin, Yang, Blood, Qi, and Jing (Essence).
As discussed earlier, the TCM term Uterus encompasses
There are eight Extraordinary Vessels:152,153
the ovaries. Thus, the Uterus acts as an Extraordinary Fu
organ, by storing and retaining151 eggs, storing the Heavenly • Chong Mai (Penetrating Vessel)
Water (menses), and releasing Pre-Natal Jing (Essence) (the • Ren Mai (Conception Vessel)
egg) at ovulation and menses at menstruation. The Uterus • Du Mai (Governing Vessel)
also stores the embryo and facilitates its development. • Dai Mai (Girdling Vessel)
The Uterus, with the aid of the Zangfu organs and • Yinqiao Mai (Yin Motility Vessel)
Extraordinary Vessels (and the Brain), facilitates the com- • Yangqiao Mai (Yang Motility Vessel)
pletion of the whole embryological process and the forma- • Yinwei Mai (Yin Linking Vessel)
tion of the embryo and foetus.151 • Yangwei Mai (Yang Linking Vessel)
The Extraordinary Vessels, in particular the Ren (Concep- This section focuses on the Chong, Ren, Du, and Dai Mai
tion), Du (Governing), and Chong (Penetrating), occupy (Penetrating, Conception, Governing, and Girdling Ves-
the centre of the Uterus.149 (The Section ‘The key sels) because they play a critical role in fertility. The Chong,
Extraordinary Vessels in reproduction’ later in this chapter Ren, and Du Mai (Penetrating, Conception, and Governing
discusses this in more detail.) Vessels) connect to the Uterus and are affiliated with the
The Uterus receives Pre-Natal Jing (Essence) from the Stomach, Kidney, Liver, and Spleen. The Du Mai (Govern-
Kidney and Qi and Blood from the Heart. The Uterus is ing Vessel) enters the Brain and connects to the Kidney
connected to the Heart ‘as if it was its own viscera’149 and Heart.
50
Anatomy and physiology of the reproductive system Chapter |2|
The Extraordinary Vessel pathways are discussed in this through the throat to the lower cheek, moves around the
section because they illustrate interrelationships that have lips, and travels to below the centre of the eyes.156
fundamental roles in women’s reproductive physiology. The main functions of the Du Mai (Governing Vessel) are:
• Mastering Yang Qi165 and connecting Yang
meridians89
The Chong Mai (Penetrating Vessel)
• Entering the Kidney, Heart, and Brain156
The Chong Mai (Penetrating Vessel) originates in the area • Governing fertility and conception165 by influencing
between the Kidneys, travels through the Uterus to REN1, male and female genitals165
then to ST30 (the meeting point of the Chong Mai), where • Together with the Ren Mai (Conception Vessel),
it emerges.73 maintaining a balance of Yin and Yang89
It then travels with the Stomach153,154 or Kidney155,156
The Du Mai’s (Governing Vessel’s) affiliation with the
meridian alongside the umbilicus, reaches the chest, and
Kidney, Heart, Brain, and Liver creates a supportive envi-
disperses.153–156
ronment for fertilization, conception, implantation, and
Ling Shu 38 describes a branch of the Chong Mai that
pregnancy. For example, DU20 is the meeting point of
travels down the leg and nourishes the Liver, Spleen, and
the Du Mai (Governing Vessel) with the Liver.166 It raises
Kidney meridian.157,158
and stabilizes Yang, interrelates the body with Heaven,
The main functions of the Chong Mai (Penetrating
and provides a calming effect on Shen (Spirit). This point
Vessel) are:
can be used before an embryo transfer and for early preg-
• Connecting Pre- and Post-Natal Jing (Essence) and Qi159 nancy support. Acupuncture and moxibustion on DU4 is
• Mastering all circulation158–161 and regulating Qi and often used to tonify the Kidney for fertility and conception
Blood,158–161 the Uterus,73 and the menstrual cycle to purposes.
benefit fertility and conception162 The Ren Mai (Conception Vessel) and the Du Mai (Gov-
• Providing Yang with Jing (Essence) and Blood159 erning Vessel) arise together,142 sustaining an essential bal-
• Warming Mingmen (Fire of Life)163 ance and maintaining Yin and Yang function.32 However,
• Receiving Jing (Essence) and assistance from the Unschuld, Tessenow and Jinsheng state that the Du Mai
Kidney meridian79,89 (Governing Vessel) is assigned a more important role80
• Nourishing the Kidney, Liver, and Spleen and warming in reproductive health than the Ren Mai (Conception Ves-
collaterals157,164 sel) because it enters the Kidney, Heart, and Brain. Accord-
The Chong Mai (Penetrating Vessel) is used to improve and ing to TCM concepts, it is through these connections that
ensure a good and appropriate amount and flow of Qi and fundamental physiological changes in fertility, conception,
Blood in the Uterus. The Chong Mai (Penetrating Vessel) and early pregnancy happen.
connects with Pre- and Post-Natal Jing (Essence), the Thus, with so many connections with male and female
Kidney, and the Stomach. It improves reproductive health genitalia, disorders in the Kidney, Heart, and Brain in both
and fertility by nourishing the Kidney and warming Ming- classical TCM literature and contemporary TCM infertility
men. The Chong Mai (Penetrating Vessel) also nourishes practice are believed to be caused by disorders of the Du
the Liver and the Spleen164 and provides the Uterus with Mai (Governing Vessel).155
Jing (Essence) and Blood for healthy menses. For this rea-
son, it is called the Sea of Blood.
The Ren Mai (Conception Vessel)
The Ren Mai (Conception Vessel) originates in the area
The Du Mai (Governing Vessel) between the Kidneys, travels to the Uterus, and emerges
The Du Mai (Governing Vessel) originates in the area at REN1.73 It then ascends inside the abdomen through
between the Kidneys, travels to the Uterus, and emerges the acupuncture point REN4 toward the throat.153,154
at REN1.73,153 The Ren Mai (Conception Vessel) meets with the Liver
It then travels to its primary point DU1, ascends inside meridian at REN2, the Spleen meridian at REN3, and the
the spine up to DU16, and enters the Brain.153,154 Kidney meridian at REN4.32
Su Wen 60 describes in detail the importance of the Du The main functions of the Ren Mai (Conception
Mai (Governing Vessel) in reproductive anatomy and phys- Vessel) are:
iology and how the Du Mai (Governing Vessel) tracks the • Facilitating menarche and fertility142 by receiving
female genitalia and, in the male, travels along the penis.156 nourishment from Pre- and Post-Natal Jing
Su Wen 60 also describes how the Du Mai (Governing (Essence)89,131
Vessel) merges with the Kidney meridian, enters the spine, • Controlling and nourishing Yin through governing Jing
and connects with the Kidneys.156 (Essence),142 Bodily Fluids, and Blood89
Su Wen 60 states that the Du Mai (Governing Vessel) pen- • Enabling conception by governing the Uterus and
etrates the umbilicus, ascends and enters the Heart, travels menses89
51
Acupuncture for IVF and Assisted Reproduction
Table 2.2 Key differences between Chong, Du, and Ren Mai (Penetrating, Governing, and Conception Vessels)
52
Anatomy and physiology of the reproductive system Chapter |2|
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107. Lyttleton J. A tale of two clinics – the 117. Stricker R, Eberhart R,
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the abbott ARCHITECT analyzer. palaces, questions 30–47. In: symptomatology. In: Root C, editor.
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2004. p. 577–83 Section three: VARIETIES.pdf.
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2004. p. 513–6 Section three: Poppy Press; 1998. p. 35–44 International College of Traditional
Spiritual pivot [Ling Shu] Section 4. A discussion of the Chinese Medicine; 2004. p. 172–4
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Emperor’s golden bookcase. In: 132. Rochat de la Vallee E. Zang and Fu. 141. Li Dong-Yuan. Treaties on the
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internal medicine and the difficult in Chinese classical texts. Norfolk: Spleen. In: Yang S, Li J, translators.
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Vancouver: International College of 133. Maciocia G. The functions of the Spleen and Stomach: a translation
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questions [Su Wen] [chapter 4]. text for acupuncturists and Section 1 [chapter 1].
125. Larre C, Rochat de la Vallee E. Nan herbalists. Edinburgh, New York: 142. Larre C, Rochat de la Vallée E. Ren
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126. Unschuld PU. Medical thought birth. In: Unschuld PU, translator. 143. Liu F. Book one. Medical essays. The
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[chapter 8]. 1998. p. 140–2 [chapter 15]. p. 3–12.
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144. Lu HC. Five separate channels of the the Yellow Emperor’s classics of translation of the Yellow Emperor’s
Body Fluids and their blockage. In: internal medicine and the difficult classics of internal medicine and the
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(Nei-Jing and Nan-Jing). Vancouver: p. 601–6 Section four: Difficult clas- Medicine; 2004. p. 492–4
International College of Traditional sic [Nan Jing] [chapter 2]. Section three: Spiritual pivot
Chinese Medicine; 2004. p. 498 154. Unschuld PU, translator and [Ling Shu] [chapter 33].
Section three: Spiritual pivot annotator. The conduits and 161. Lu HC. On paralysis. In: A complete
[Ling Shu] [chapter 36]. vessels. Difficult questions 23–29. translation of the Yellow Emperor’s
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Jinsheng Z. Discourse on how the Nan-Ching. Medicine in China. The difficult classic (Nei-Jing and Nan-
Qi in depots follow the pattern of Classic of Difficult Issues, The Jing). Vancouver: International
the seasons. In: Huang Di Nei Jing Chinese Medical Classics. Berkeley: College of Traditional Chinese
Su Wen, vol. 1. Berkeley: University University of California Press; 1986. Medicine; 2004. p. 196–8
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p. 384–400 [chapter 22]. 155. Lu HC. On joint cavities. In: [Su Wen] [chapter 44].
146. Larre L, Rochat de la Valle E. In: A complete translation of the Yellow 162. Maciocia G. The Eight Extraordinary
Root C, editor. The Lung, revised ed. Emperor’s classics of internal Vessels (part 2). J Chin Med
Norfolk: Monkey Press; 2001. medicine and the difficult classic 1989;30:3–8.
p. 1–85. (Nei-Jing and Nan-Jing). Vancouver: 163. Rochat de la Vallee E. The
147. Maciocia G. The functions of the six International College of Traditional Extraordinary Meridians. In:
Extraordinary Yang organs. In: The Chinese Medicine; 2004. p. 231–4 Root C, editor. The essential
foundations of Chinese medicine: Section two: Essential questions women, female health and fertility
a comprehensive text for [Su Wen] [chapter 60]. in Chinese classical texts. Norfolk:
acupuncturists and herbalists. 156. Unschuld PU, Tessenow H, Monkey Press; 2007. p. 47–53.
Edinburgh; New York: Churchill Jinsheng Z. Discourse on bone 164. Jianghan M. The Extraordinary
Livingstone; 1989. p. 123–5 hollows. In: Huang Di Nei Jing Su Channel Chong Mai and its clinical
[chapter 14]. Wen, vol. 2. Berkeley: University of applications. J Chin Med
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Root C, editor. The essential [chapter 60]. 165. Larre C, Rochat de la Vallée E. Du
women, female health and fertility 157. Lu HC. Techniques of acupuncture Mai. In: Hill S, editor. The
in Chinese classical texts. Norfolk: as applied on normal and abnormal Eight Extraordinary Meridians.
Monkey Press; 2007. p. 18–25. energy flow and on flat and thin Norfolk: Monkey Press; 1997.
149. Larre C, Rochat de la Vallée E. The pulses. In: A complete translation of p. 23–84.
Bao. In: Root C, editor. The the Yellow Emperor’s classics of 166. Deadman P, Al-Khafaji M, Baker K.
Extraordinary Fu. London: Monkey internal medicine and the The Governing Vessel. In: A manual
Press; 2003. p. 159–94. difficult classic (Nei-Jing and of acupuncture. England: Journal of
150. Lu HC. A discerning treatise on five Nan-Jing). Vancouver: Chinese Medicine Publications;
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the Yellow Emperor’s classics of Chinese Medicine; 2004. p. 500–2
167. Deadman P, Al-Khafaji M, Baker K.
internal medicine and the difficult Section three: Spiritual pivot
The Kidney channel. In: A
classic (Nei-Jing and Nan-Jing). [Ling Shu] [chapter 38].
manual of acupuncture. England:
Vancouver: International College of 158. Lu HC. Pulsating spots and Journal of Chinese Medicine
Traditional Chinese Medicine; 2004. transmission of energy. In: Publications; 1998. p. 329–64.
p. 111–2 Section two: Essential A complete translation of the
168. Lu HC. Separate master meridians.
questions [Su Wen] [chapter 11]. Yellow Emperor’s classics of
In: A complete translation of
151. Unschuld PU, Tessenow H, internal medicine and the difficult
the Yellow Emperor’s classics of
Jinsheng Z. Further discourse on the classic (Nei-Jing and Nan-Jing).
internal medicine and the
Five depots. In: Huang Di Nei Jing Su Vancouver: International College of
difficult classic (Nei-Jing and
Wen, vol. 1. Berkeley: University of Traditional Chinese Medicine;
Nan-Jing). Vancouver:
California Press; 2011. p. 203–10 2004. p. 539–40 Section three:
International College of
[chapter 11]. Spiritual pivot [Ling Shu]
Traditional Chinese Medicine;
[chapter 62].
152. Larre C, Rochat de la Vallée E. 2004. p. 438–42 Section three:
Introduction. In: Hill S, editor. The 159. Larre C, Rochat de la Vallée E. Chong Spiritual pivot [Ling Shu]
Eight Extraordinary Meridians. Mai. In: Hill S, editor. The Eight [chapter 11].
Norfolk: Monkey Press; 1997. Extraordinary Meridians. Norfolk:
169. Larre C, Rochat de la Vallée E. Dai
p. 1–22 [chapter 1]. Monkey Press; 1997. p. 107–32.
Mai. In: Hill S, editor. The Eight
153. Lu HC. Meridians (questions 160. Lu HC. On the four seas of the Extraordinary Meridians. Norfolk:
23–29). In: A complete translation of human body. In: A complete Monkey Press; 1997. p. 133–57.
58
Chapter |3|
The magic of conception
For many of our patients, conception is still possible, for sexual response exist, but most models describe four main
example, while they are waiting for Assisted Reproductive stages:
Technology (ART) treatment to begin. They want to under- • Desire, excitation, and arousal
stand how to increase their chances of conception by • Plateau
understanding what happens in their body at different • Orgasm
stages of conception. They may ask questions, such as what • Resolution
exactly happens during ovulation, when is the fertile win-
During the initial stage of desire, excitation, and arousal,
dow, and when does the embryo implant. This chapter will
genital tissues become engorged with blood, resulting in
introduce the reader to key events that happen before,
an erection of the penis in men and of the clitoris and labia
during, and after conception.
in women.1 Engorgement causes lubricating fluids (also
The ability to conceive naturally depends on several key
known as mucus) to ooze through the skin, more so in
components. A woman must ovulate and release a mature
women (partly from the vagina and partly from the cervix).
egg. Sperm must be ejaculated inside the female reproduc-
Men also contribute a small amount of mucus. Inadequate
tive tract through sexual intercourse. Sperm needs to pass
amounts of these fluids will lead to painful intercourse,
through the vagina and uterus and get into the fallopian
which may inhibit the potential for orgasm.
tubes where it will remain until the egg is ovulated. The
Sexual arousal is enhanced by direct physical contact,
egg must then be fertilized by a single spermatozoon
such as kissing and rubbing.1 Some authors argue that
and, while dividing, travel down the fallopian tube and
higher levels of arousal are better for conception.2 Antici-
into the uterus where it must implant.
pation of pain or discomfort, tension, or stress may reduce
Other factors that affect the chances of conception are the
the level of sexual excitement and, therefore, affect sexual
maternal uterine environment, correct hormonal balance,
arousal. Although having frequent intercourse during the
and practical aspects, such as sexual intercourse. This
fertile window can help increase the odds of conception,
chapter discusses each of these elements in greater detail.
both partners may find it too stressful to be able to ‘perform
It also examines what Traditional Chinese Medicine
on demand’. This may result in erection issues in men and
(TCM) views as key components of conception.
lack of lubrication in women.1
The period of excitement and arousal can last just a few
seconds or many minutes. During the late stages of arousal,
SEXUAL INTERCOURSE the distal third of the vagina swells and grips the penis
tightly. This helps to stimulate the penis more strongly
Sexual intercourse (also known as coitus – a coming to- and orgasm usually follows although not always and not
gether) is required for unassisted conception to happen. necessarily simultaneously in both partners.1
Couples often refer to intercourse as ‘baby dancing’ or Men usually ejaculate during orgasm. Both men and
‘BD’. Sperm needs to be inseminated inside the vagina. From women usually experience several rhythmic muscular con-
there it will travel through the uterus and into the fallopian tractions during orgasm. Some experts3,4 believe that these
tubes where it will fertilize the egg. Several models of human contractions in women may help to propel sperm quickly
into the uterus and inside the fallopian tubes. However, as transport although they may potentially assist it.9 Sperma-
Levin has noted, this opinion is based on only three tozoa are transported mostly via their own activity.2,9
anecdotal cases.2 From the cervix, sperm travels upward through the uterus
After an orgasm, a couple usually remain motionless. toward the fallopian tubes. Sperm is estimated to swim
Leaving the penis inside the vagina until it becomes flaccid through the uterus at a speed of 5 mm/min. As the uterus
(between 5 and 10 min) helps with the painless withdrawal is only a few centimetres in length, it would take around
of the penis.2 10 min for sperm to reach the fallopian tubes.10 Uterine
smooth muscle contractions aid sperm movement. In
one study, sperm was found in the fallopian tubes just
5 min after insemination.11 However, these findings are
SPERM TRANSPORTATION UP THE
dismissed by most authors because the women in this study
FEMALE REPRODUCTIVE TRACT were anaesthetized, not sexually aroused, and the semen
was pre-incubated and placed directly into the cervical
The journey sperm makes up the female reproductive tract os. Another study showed that it can take up to 1 h for
is tough. Out of 300–500 million ejaculated spermatozoa, sperm to reach the tubes.12 The longer transit time in this
less than 1% reach the egg.5 First, sperm has to survive the study might have been caused by uterine abnormalities,
mechanical stress of the ejaculation process (estimated to such as fibroids, polyps, and endometriosis whilst shorter
happen at 28 miles/h)6 and the biochemical hazard of times in other studies do not necessarily mean fertilization
oxidative stress as it passes through many defensive mech- is possible because the physical stress of going too quickly
anisms in the female reproductive tract. After ejaculation, through the tubes may possibly cause damage to sperm.7
sperm pools in the anterior vagina near the cervical os Although some sperm have been found in the cervix 5 days
(opening of the uterus). The physiological benefit of being after insemination, it is unlikely that many sperm would be
deposited here is that it can quickly escape (within able to reach the fallopian tubes 24 h after ejaculation.7
minutes) the tough environment of the vagina, which The entrance to the fallopian tubes at the uterotubal
protects the reproductive tract from the outside influences, junction is narrow but fairly easy for sperm to pass
such as infection.7 through.7 The fallopian tubes contain viscous mucus,
Within a minute of being ejaculated, the semen forms a but, unlike the vagina, cervix, and uterus, the fallopian
gel (coagulates). Coagulation serves to hold sperm by the tubes are fairly safe for sperm because the tubes do not
cervical os and may have a protective function against mount an immunological defence. The fallopian tubes
the harsh environment of the vagina.7 On average, only are believed to act as storage for sperm and help to main-
65% of sperm enter the cervical mucus. In a study done tain the potency of sperm until ovulation. When in the fal-
by Baker and Bellis, they observed that 35% of sperm are lopian tubes, the sperm bind to the epithelium lining. This
lost through flowback into the vagina. This happens approx- process has been shown to be disrupted in women with
imately 30 min after coitus. This flowback was observed in endometriosis.13 The fallopian tube mucus and epithelial
94% of copulations. However, in 12% of copulations, binding help to slow down sperm progression toward
almost 100% of sperm were lost. Female orgasm between the ampulla part of the fallopian tubes, thus reducing
1 min before ejaculation and up to 45 min after increases the chance of polyspermic fertilization (where the egg is
sperm retention.8 fertilized abnormally by more than one sperm).7
Once in the cervix, sperm mixes with cervical mucus.
Cervical mucus composition changes throughout the
menstrual cycle. During the most fertile time of the cycle,
the mucus is most hydrated and is more than 96% water.
The structure of cervical mucus helps to filter out normal
PREFERTILIZATION SPERM CHANGES
and abnormal sperm as well as assist sperm in transporta-
tion. The female immune system mounts an immune In order to fertilize the egg, sperm undergo two changes:
response to the presence of sperm, stimulating migration capacitation and hyperactivation (hypermobility).7,14 Capac-
of leukocytes (mainly neutrophils and macrophages). itation, possibly the greatest discovery in ART, was discov-
However, these leukocytes take time to build up and do ered in 1951 by Chang and Austin; it is a process in which a
not form a significant barrier to sperm transportation unless sperm sheds its major protein coating. This protein facili-
the females become immunized against sperm and form tates a sperm’s movement through the cervical mucus
anti-sperm antibodies. In these cases, neutrophils will and helps it bind to the epithelium of the fallopian tubes.14
bind to sperm and destroy it. Immunoglobulins (IgG and In 1969, when Robert Edwards and his colleagues reported
IgA) are also secreted in cervical mucus to fight bacteria.7 successful in vitro maturation and fertilization of human
It is interesting to note that vaginal, cervical, and uterine oocytes, they attributed their success to the capacitation
contractions often present in the pre-orgasmic and orgas- research done by Chang and Austin.15 Capacitation is
mic phases are not actually required for effective sperm believed to happen in the fallopian tubes.
60
The magic of conception Chapter |3|
Once the protein coat is shed, sperm unbind from the for ovulation will be disrupted;1 this is how many
fallopian tube epithelium and move toward the egg. This hormonal contraceptive pills work.
stage is facilitated by sperm hyperactivation, the process The high levels of LH trigger continuation of the first
where the velocity of sperm increases;14 this process involves meiotic division of the egg (oocyte).19 When meiosis I is com-
a change in the flagellar (tail) beating.7 Capacitation and pleted, the oocyte will have two cells: a bigger one (the sec-
hyperactivation are believed to be triggered by chemical ondary oocyte), which has most of the cytoplasm, and a
and hormonal signals released by the pre-ovulatory follicle. smaller one (the polar body) consisting of a nucleus. Mei-
Hyperactivation is also thought to help sperm penetrate the osis II of the secondary oocyte follows immediately after
zona pellucida.7 meiosis I is completed, but the oocyte arrests in the meta-
When sperm reach the egg, they undergo the acrosome phase and will remain in this phase until fertilization.19
reaction. This is where the spermatozoa plasma membrane At this stage, the egg is considered to be mature. The follicle
and the outer acrosomal membrane breakdown and merge, then ruptures, and the egg is released. This is called ovula-
the change that is required for the egg and sperm to fuse.14 tion, and, for many women, this occurs on day 14 in a 28-
The acrosome reaction is triggered by sperm binding to the day cycle.1 Meiosis II is completed once the egg is fertilized.
outer shell of the egg, the zona.16 The remainder of the ruptured follicle collapses and,
In summary, after insemination in the vagina, sperm under the influence of LH, becomes luteinized. It is now
move as quickly as possible through the cervix and uterus referred to as the corpus luteum. The main function of corpus
and bind to the epithelial lining of the fallopian tubes. Out luteum is to produce progesterone, oestrogen, relaxin, and
of 300–500 million ejaculated sperm, fewer than 1% reach inhibin.1 These hormones are necessary for the uterine
the egg.5 Here sperm wait for a signal that the egg is about lining to be maintained and, if fertilization occurs, to
to be ovulated (sometimes as long as 5 days), at which support the embryo. The lifespan of the corpus luteum is
point spermatozoa unbind from the epithelium of the fal- 2 weeks, at which point it degenerates into a corpus albicans.1
lopian tubes, undergo chemical changes, and move toward However, if fertilization has occurred, the embryo will
the ampulla part of the fallopian tube where they attempt start to produce Human Chorionic Gonadotropin (hCG)
to fertilize the egg. hormone, and this rescues the corpus luteum, which in turn
continues producing hCG until approximately 10 weeks’
INTERESTING FACTS gestation when the placenta takes over hCG production.
61
Acupuncture for IVF and Assisted Reproduction
spermatozoon of the same species, thus preventing cross tissue.22 Blastomeres are totipotent, meaning that until the
species reproduction.19 The spermatozoon binds to the embryo has four to eight cells (usually 2–3 days after fertili-
zona pellucida for approximately 1 min and then pene- zation), blastomeres are not destined to grow into any partic-
trates it. The penetration involves a physical thrust of the ular tissue. Animal studies show that, during this phase, an
tail and rapid lateral oscillations of the head. Fertilization embryo can be split into two, each part potentially capable
takes place near the ampullary–isthmic junction.20 of growing into a separate viable offspring.22
As already discussed in Chapter 2, when the egg is pene- This is one of the methods of cloning that would result in
trated by a spermatozoon, the egg is activated, and meiosis II monozygotic (identical) twins. Other methods of cloning
is completed (approximately 3 h later).14 At the end of this exist, for example, where a nucleus is transferred from
stage, two further cells are formed: a bigger cell that has most donor cell into an egg that has no nucleus, resulting in
of the cytoplasm and the second polar body. Now the egg an identical genetic copy of the first cell. Any method of
cell and the sperm cell (each carrying 23 chromosomes) tissue cloning for the purpose of reproduction is highly
can fuse.19 Fusion of the egg and sperm results in the forma- controversial, and, so far, all cloned embryos have been
tion of a zygote,21 from Greek meaning joined. This is the ear- destroyed before 14 days development.
liest developmental stage of the embryo, and it contains the
DNA of both parents. The zygote phase ends when the egg
and sperm pronuclei merge together.5,22 Once the egg is fer- COMPARISON OF NATURAL
tilized, the zona pellucida becomes impervious to other FERTILIZATION (IN VIVO) WITH ART
sperm.5,14 Once meiosis II is completed, the second polar FERTILIZATION (IN VITRO)
body is released, and the now fertilized egg contains 46 chro-
mosomes, 23 from the sperm and 23 from the egg. The
newly formed embryo has two cells, and it is now ready The main differences between a natural cycle and ART
to migrate down the fallopian tube and continue dividing. treatment cycle are outlined in Table 3.1.
EMBRYOGENESIS
TRANSPORTATION OF THE EMBRYO
DOWN THE FEMALE REPRODUCTIVE
Embryogenesis refers to the process of embryo develop-
TRACT ment, starting from the moment the egg and sperm fuse
(fertilization) to approximately 8 weeks after fertilization.
After ovulation, the egg is inside the fallopian tube within From this point on, the embryo is referred to as a foetus.
15–20 min14 where it is fertilized; the fertilized egg takes When a sperm penetrates the egg, embryogenesis begins
approximately 3.5 days23 or 80 h14 to travel through the with the formation of a one cell zygote (Figure 3.1), which
fallopian tube before it enters the uterus. It is aided by is defined as an embryo because it contains a full set of
ciliary beating, smooth muscle contractions, and tubal chromosomes. When the pronuclei of the egg and sperm
mucus.24 Ninety percent of this time is spent near the merge, a two-celled embryo is created and is no longer
junction of the ampulla and the isthmus of the tube where called a zygote. This two-celled embryo continues dividing,
fertilization is believed to take place.14 a process called cleavage.
There is evidence that the embryo is able to slow down its The first division of the zygote begins 24 h after fertiliza-
transportation from 133 mm/s (prefertilization) to 46 mm/s tion and completes 30 h after fertilization.5 By the end of
(postfertilization). This helps the embryo start its communi- the second day after fertilization, an embryo is expected to
cation with its mother. The characteristics of the fallopian have four cells.25 By the end of day 3, there will be around
tube containing a fertilized egg are different from the eight cells.25 When the embryo has divided into 8 cells, it
physiology of the tube on the opposite side of the body, sug- starts the process of compaction (where cells bind very
gesting that the embryo triggers a reaction in the tube that tightly together), and the embryo enters the morula stage
ensures the embryo’s optimal microenvironment and with 32 cells22 approximately 4 days after fertilization.5
nutrition during the first 24–48 h after fertilization.23 Throughout this time, the embryo travels down the fallopian
A small proportion of embryos implant in the fallopian tube. Over the next 24 h, cavitation occurs, where an outer
tube, resulting in an ectopic pregnancy. This type of cell layer (trophectoderm) begins to pump fluid inside the
pregnancy is not viable and is potentially life threatening, embryo. This is the first time that the embryo not only keeps
often resulting in surgical removal of the damaged tube dividing into further cells (40–150 cells) but also starts to
(see Chapter 12 for more detailed information on ectopic expand. This phase is called the blastocyst stage, and the
pregnancies). embryo will have now reached the uterus. The blastocyst
As the embryo moves down the tube, its cells (blastomeres) is made of a trophoblast (an outer layer of cells that becomes
divide very rapidly, 18 h for each cell. This speed of division is the placenta), an inner cell mass (most of which develops
only comparable to tumour cells or to regenerating somatic into the embryo), and a blastocoele (hollow space).5
62
The magic of conception Chapter |3|
INTERESTING FACTS
OVULATION AND FERTILIZATION
® LH surge occurs at approximately 3 am,
beginning between midnight and 8 am in two-thirds
of women.27
® Ovulation happens mostly in the morning in spring
(50% of women ovulate between midnight and 11 am)
and in the evening during autumn and winter (90% of
women will ovulate between 4 and 7 pm).28
® Ovulating from the right ovary is more frequent
(55% of ovulations) and more likely to result in
conception.29
® Younger women often ovulate from alternate ovaries.
Women over the age of 30 ovulate more frequently
from the same ovary. A contralateral pattern of
ovulation is more likely to result in pregnancy.30
Figure 3.1 Fertilized egg showing two pronuclei. ® A fallopian tube can pick up the egg released by the
Courtesy of Mr A. Gorgy at The Fertility and Gynaecology Academy
ovary on the contralateral side.14
and City Fertility, London, UK.
® A woman is more likely to ovulate the more nights she
spends sleeping next to a man. One study found that
92% of women who slept next to a man for more than
Eventually, the embryo can no longer expand within the
one night in a 40-day period ovulated, compared to
zona pellucida (its shell) and it hatches, usually on day 6 56% of women who slept next to a man for a day or less
or 7 postfertilization22 or 72 h after the embryo enters the in a 40-day period.31 Perhaps this presents an example
uterus.26 The implantation stage begins. All of these stages of the TCM theory on the interaction of Yin and Yang,
are sometimes referred to as the conceptus stage.21 where one depends on another (female being Yin and
Table 3.2 and Figures 3.2 and 3.3 summarize different stages male being Yang).
of embryo development.
63
Table 3.2 Summary of embryo development stages
Figure 3.2 Embryo development: (a) two-cell embryo; (b) four-cell embryo; (c) eight-cell embryo; (d) early blastocyst;
64
The magic of conception Chapter |3|
Cleavage
Fusion of egg
and sperm
pronuclei
Blastocyst
Fertilization
Implanted
blastocyst
Ovum
Figure 3.3 Embryo development and transportation down the female reproductive tract.
65
Acupuncture for IVF and Assisted Reproduction
66
The magic of conception Chapter |3|
Uterine stroma
Syncytiotrophoblast
Amnionic cavity
Cytotrophoblast
Endoderm
(c)
Blastocoel (yolk sac cavity)
Sinusoids
filled with maternal
blood
Syncytiotrophoblast
Amnionic
cavity
Yolk sac
cavity
(d)
67
Acupuncture for IVF and Assisted Reproduction
‘As both fine spirits are drawn to each other, they The physiology of fertilization, according to the Yin Yang
unite and fit together to complete the human form. This classification of IVF, involves the male sperm (Yang) fertil-
precedes the life of the physical body. This is the function izing the female egg (Yin). The egg (Yin) is the foundation
of the Essences’.47 for fertilization, and the sperm (Yang) is the instigator. This
‘When two spirits struggle against each other is not so dissimilar from a concept in classical Chinese
and meet together to form physical shape a fetus medicine where life begins in Yin.
will come into existence. The energy responsible
for this formation is called pure energy (Essence)’.48 ‘At first the embryo is brought into being by a
combination of two energies called Yin and Yang’.51
Traditional Chinese Medicine ‘The fetus is created by the interaction and mutual
stimulation of Yin [female] and Yang [male]’.52
The creation of an embryo in TCM can be described as
‘Yin and Yang blend in harmony, the two qi
transformation. For example, Water assumes form and
respond to each other, and yang bestows and yin
new life begins, or male and female Jing (Essences) unite
transforms’.53
and transform to create a human being.45,47,48
TCM also discusses Mingmen (the Fire of Life) as essen-
tial for conception (see Chapter 2). Mingmen (the Fire of The embryo’s energy (Pre-Natal Qi)
Life) is created by Water49 and is regulated by the Kid- Larre et al. discuss TCM physiology before birth, in other
neys.49 The embryo is created through Jing (Essence) of words, the physiology of the embryo and foetus.54 The
the Kidneys and Mingmen (the Fire of Life).49 embryo is said to be made up of four Qi (Figure 3.6)
Mingmen (the Fire of Life) is housed by the Gate of although it is important to remember that the four aspects
Life, which is housed by the Kidney (see Chapter 2). It is operate in unity and are not separate entities.
associated with the origin of life and is therefore essential
for conception. • Yuan (Original) Qi
• Kidney Jing (Essence)
• Zhen (True) Qi
Conception in IVF or by ICSI from • Shen (Spirit)
the TCM point of view The prefertilization Qi of the male and the female combine
to produce the Qi of the resulting embryo.54 In other
In IVF, fertilization occurs outside the body (in the labo- words, the embryo is a direct expression of its parents’ Qi.
ratory dish), resulting from the combination of the sperm
and egg Jing (Essences) (Figure 3.5).
As discussed in Chapter 2, the egg and sperm are
Yuan (Original) Qi
Kidney Jing (Essence) and are influenced by Blood and The sperm and egg at the time of fertilization transmit Yuan
Qi. Fertilization and the resulting embryo is a consequence (Original) Qi. It is the original supply of Yang and Yin of
of combining Kidney Jing (Essences).47–51 the embryo. Yuan (Original) Qi initiates and facilitates
Jing (Essence)
Jing (Essences)
Sperm
Sperm and egg
combine
(Yang)
MOTHER
Jing (Essence)
Egg (Yin)
68
The magic of conception Chapter |3|
Yuan
Embryo Shen (Spirit)
(Original) Qi
the development of the embryo and remains the source of • Sexual intercourse (coitus)
life of the person,54 from the embryonic state (in vivo or • A healthy sperm
in vitro) and throughout adulthood. • A healthy egg
• Ability of sperm to fertilize the egg
Pre-Natal Jing (Essence) • Free passage of sperm and egg in the female
Kidney Jing (Essence) creates and nourishes55 the embryo. The reproductive tract
embryo is derived from the parents’ reproductive organs. Kid- • Uterine environment receptive to the embryo
ney Jing (Essence) of the parents unite to become the embryo. • Properly regulated hormonal balance and the
The father and mother pass on their Jing (Essence) at the time menstrual cycle
of fertilization. The grading of the embryo for the purposes of
ART (see Chapter 6) and the way it divides depends on the par- The quality of the embryo greatly influences the chances
ents’ state of health and their Jing (Essence). of successful conception. Parental energy influences the
quality and potential of embryonic development and,
Zhen (True) Qi hence, greatly influences the success of IVF treatment.
Therefore, in order to optimize their reproductive
The correspondence between Heaven and Earth56,57 is
health, it is essential to assess and treat both parents’
Zhen (True) Qi. Zhen (True) Qi resembles and represents
Kidney Yin and Yang, Blood, and Qi during the
natural order,57 the law of nature, and transformation of
preconceptual phase.
Qi.58 Zhen (True) Qi initiates the possibility of concep-
tion57 along with the parents.
Shen (Spirit)
Shen (Spirit) is responsible for the vitality of the embryo ACKNOWLEDGEMENT
and lays the earliest foundation for the character of the
newly conceived individual.54 Energies discussed at the time of conception – the type,
nature, and physiology – have been further developed via
personal communications and courtesy of Elisabeth
SUMMARY Rochat de la Vallée. This concept and adaptation is some-
what different to earlier works by the authors, which are
Both Orthodox and Chinese medicines recognize that nat- stipulated in Survey of Traditional Chinese Medicine
ural conception is a complex process involving several key 1986.54
components. These components are:
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reproduction. 5th ed. Oxford: Black- 48. Lu HC. Various types of energy. In: A gynecology, vol. 2. Portland: The
well Science; 2000. p. 194–202 complete translation of the Yellow Chinese Medicine Database; 2008.
[chapter 11]. Emperor’s classics of internal p. 52–216 [chapter 2].
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Arici A. Basic aspects of implantation. (Nei-Jing and Nan-Jing). Vancouver: et al. The differential energies. In:
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41. Edwards RG. Human implantation: Section three: Spiritual pivot [Ling Institut Ricci; 1986. p. 111–39, Part 2
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42. Wilcox AJ, Weinberg CR, Janzen JM, Leslie C, editors. Medicine for acupuncturists and herbalists.
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1988;319:189–94. p. 189–228 [chapter 8]. [chapter 3].
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and early pregnancy loss in natural Jing difficulty 39. In: Root C, editor. Jinsheng Z. The five periods,
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Gynaecol 1991;5:179–89. dles; 1989. p. 14–7. In: Huang Di Nei jing Su Wen:
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71
Chapter |4|
Orthodox medical tests and investigations:
Optimizing patient care
Being able to interpret results of subfertility tests and inves- Gynaecologists (RCOG), and the World Health Organiza-
tigations is of vital importance to fertility acupuncturists. tion (WHO), proposed the following protocol for a pri-
The knowledge gained can provide information about a mary care physician dealing with a subfertile couple.2
patient’s medical diagnosis and prognosis; therefore, it
can help the acupuncturist to better plan treatment. For
example, if a patient’s tests results show that her level of Medical history
Follicle-Stimulating Hormone (FSH) is very high, this
One of the first things a doctor should do is take a detailed
may be a sign of poor ovarian reserve. This patient may
medical and fertility history. It is recommended that both
potentially need to be rapidly referred for In Vitro Fertiliza-
partners should be interviewed not only together but
tion (IVF). A consensus view of some of the world’s leading
separately as well because they may wish to disclose infor-
acupuncturists who specialize in the treatment of subferti-
mation when their partner is not present that they would
lity is that ‘biomedical information should inform deci-
otherwise not disclose.2 A female partner may be asked
sions about (acupuncture) diagnosis and treatment’.1
questions about:2
This chapter explains what tests should ideally be done at
various stages of subfertility treatment, how to interpret • Present history
them, the implications, and the optimal timing and appro- n Age
priateness of each test. n Current problem/complaint
n Occupation
n Recent cervical smear findings
n Breast changes (milk discharges)
THE INITIAL CONSULTATION n Excessive hair growth with or without acne on the
face and chest
After a certain period of unsuccessfully trying for a baby, a n Hot flashes
couple may realize that they need help and visit their doc- n Eating disorders
tor. What will happen to them then will depend on the n Current associated medical illness (diabetes,
experience and specialist knowledge of that doctor, the hypertension)
local regulations and policies, and, in many cases, the avail- n Medication currently being taken
ability of funding for that couple’s treatment. n Sex steroid, cytotoxic or recreational drug intake
A 2010 review by the world’s top authoritative organiza- n Smoking
tions in the field of reproduction, including the American n Alcohol consumption
College of Obstetricians and Gynecologists (ACOG), the n Caffeine consumption
American Society for Reproductive Medicine (ASRM), the • Menstrual history
Canadian Fertility and Andrology Society (CFAS), the Euro- n Age of menarche
pean Society of Human Reproduction and Embryology n Cycle characteristics and associated symptoms (such
(ESHRE), the Human Fertilisation and Embryology as spotting or pain)
Authority (HFEA), the Royal College of Obstetricians and n History of primary or secondary amenorrhoea
74
Orthodox medical tests and investigations Chapter |4|
n Size and shape of clitoris, hymen, vaginal introitus take into account the couple’s preferences, patient age,
n Site, size, shape, surface, consistency, mobility, and the duration of infertility, and unique features of the
direction of uterus medical history and physical examination’.3
n Palpable adnexal mass
n Vaginal discharge or tenderness Both US and UK guidelines recommend that a couple who
n Uterosacral ligament thickening fails to conceive after 12 months or more of regular unpro-
n Nodules in the cul-de-sac (possible sign of tected intercourse should be investigated.4,5 Investigations
endometriosis or tuberculosis) after 6 months are justified in a couple if the female partner
Physical examination of a male partner should include the is more than 35 years old,4,5 if there is a known medical
following:2 cause of subfertility, or if there is a history of factors that
may lead to subfertility,5 for example, endometriosis or pel-
• General examination vic inflammatory disease. In couples with known infertility
n Vital signs (including blood pressure)
(for example, patients whose fertility is compromised by
n Body height, weight, and BMI
previous cancer treatment), then an early fertility specialist
n Secondary sexual characteristics
referral should be initiated.5
n Thyroid glands
n Arm span
• Breast examination
n Gynaecomastia CLINICAL TIPS
• Abdominal examination
n Abdominal mass INFERTILITY TESTS AND INVESTIGATIONS
n Organomegaly (the abnormal enlargement of ® When were the most recent tests undertaken? Any tests
organs) that are over 6 months old may need to be repeated.
n Ascites ® Have the appropriate tests been performed correctly (for
n Undescended testis example, at the right time in the menstrual cycle)? If you
n Inguinal hernia find discrepancies, then refer your patient for retesting.
n Genital examination ® Patients often say that all their tests results are ‘normal’.
n Shape and size of penis Always request a copy of the test results and check that
n Prepuce (foreskin) they are in the normal ranges.
n Position of external urethral meatus ® Treat low/high ends of normal ranges with caution
n Testicular volume (by using Prader’s orchidometer) because these may be early indications of abnormalities.
n Palpation of epididymis and vas deferens ® Some tests may need to be repeated (for example,
n Check for varicocele or hydrocele abnormal semen analysis). Check that this has
n Perineal sensation been done.
n Rectal sphincter’s tone ® Familiarize yourself with local guidelines and policies and
n Prostate enlargement adapt your treatment plan according to these guidelines.
Once a comprehensive medical history has been obtained Incorrectly timed or delayed referral for investigations can
and both partners have been thoroughly physically exam- result in IVF not being funded.
ined, there should be a preliminary diagnosis. The doctor
can decide on further management, guided by local policies
and guidelines.
Case study
75
Acupuncture for IVF and Assisted Reproduction
Table 4.1 Ovulation investigations: reference ranges for progesterone and prolactin
76
Orthodox medical tests and investigations Chapter |4|
77
Acupuncture for IVF and Assisted Reproduction
Ovarian reserve screen However, E2 levels on their own should not be used to
measure ovarian reserve.3,5,16
Diminished ovarian reserve (DOR) is defined as ‘women of E2 levels can also help to distinguish between:3
reproductive age having regular menses whose response to
ovarian stimulation or fecundity is reduced compared to • Amenorrhoea due to ovarian failure (high FSH, low
E2), which requires egg donation, and
those women of comparable age’.3 Reduced response to
ovarian stimulation is defined as <2–3 follicles or 4 • Hypothalamic amenorrhoea (normal FSH, low E2),
which requires exogenous gonadotrophin stimulation
retrieved eggs.16
for ovulation induction.
Ovarian reserve should be assessed in women at
increased risk of DOR. This includes women who:3 FSH, LH, and E2 reference ranges are shown in Table 4.2.
From the TCM point of view, FSH, E2, and LH abnormal-
• Are more than 35 years old ities are associated with impairment of the Heart and
• Have a family history of early menopause
Kidney axis. Syndromes to look for are:
• Have a history of damage to the ovaries from
chemotherapy, pelvic radiation therapy, or ovarian • Empty syndromes
surgery or have only one ovary n Kidney Jing (Essence) Deficiency
• Have unexplained infertility n Kidney Yin Deficiency20,23
24–26
• Have a history of poor response to ovarian stimulation n Empty-Heat from Yin or Blood Deficiency23
25
with gonadotrophins n Spleen Qi and Blood Deficiency
78
Table 4.3 Ovarian reserve reference ranges: AMH
From the TCM point of view, low AMH levels are associ- Inhibin B
ated with:
The use of Inhibin B hormone level tests is no longer
• Kidney Jing (Essence) Deficiency recommended in ovarian reserve testing because it is not
• Kidney Yin23 Deficiency with or without Empty-Heat a reliable measure.5,16 AMH and AFC are the gold standard
• Liver Qi Stagnation with Blood Deficiency26 measures of ovarian reserve.
• Heart and/or Spleen Qi Deficiency
80
Orthodox medical tests and investigations Chapter |4|
although, if possible, cheaper investigative methods such as carried out to assess the uterus and the patency of the
a progesterone test should be used first to detect ovulation.3 fallopian tubes.
Ultrasound can also be used to diagnose uterine pathol- As with HSG, following the procedure, women may
ogy, for example, myomas.3 However, uterine pathology is experience some discomfort, vaginal bleeding, and referred
better detected by hysteroscopy (see later in this chapter).3 shoulder pain.38 The procedure needs to be done during
Ultrasound can also be used to assess the ovaries, for the early follicular phase.38 However, unlike HSG, it
example, for the presence of endometriomas.3 requires no use of X-ray images or iodine contrast.38,39
Ultrasound can be used to assess the fallopian tubes for Hy-Co-Sy can extend the use of ordinary ultrasound to
the presence of hydrosalpinges (see the tubal pathology include detailed evaluation of adnexal architecture, uterine
section about hydrosalpinges in Chapter 8). Ultrasound cavity, myometrial assessment, and tubal patency.38
is not useful for identifying other tubal pathology.38 It is recommended that Hy-Co-Sy should be offered
Transvaginal ultrasonography is used during ART treat- instead of HSG where appropriate expertise is available.5
ment to monitor follicular and endometrial growth during Some experts feel that Hy-Co-Sy should replace HSG as
ovarian stimulation or ovulation induction.38 the first-line investigation of tubal patency.39
81
Acupuncture for IVF and Assisted Reproduction
Laparoscopy with chromotubation or dye test (dilute foreign body, endometriosis, submucous myoma, endo-
solution of methylene blue or indigo carmine (preferred)) metrial polyp, polypoid endometrium, endometrial hyper-
is an invasive tubal investigation. Laparoscopy provides plasia, and blocked ostia.43
more detailed information about the type of tubal pathol- Major guidelines on infertility investigations do not rec-
ogy and, in some instances, allows the pathology to be cor- ommend hysteroscopy as a routine investigation because it
rected during the same procedure.3 is costly and invasive and should be reserved as a secondary
investigation, for example, in patients with a history of IVF
failures.3,5 However, some experts call for hysteroscopy to
Case study be used as part of pre-IVF investigations.43 Hysteroscopy
during the cycle preceding the IVF treatment cycle has been
Tests and investigations: Endometriosis shown to nearly double the chances of conception in
patients with two or more than two failed IVF treatment
® Leona received 4 months of acupuncture treatment to
help her conceive, initially without success. cycles.44
® Leona had some signs of endometriosis, in particular,
very painful periods. She was advised to go back to her MRI
doctor and discuss further investigations.
® Leona was referred for exploratory laparoscopy. During Magnetic resonance imaging (MRI) can be used to assess
the procedure, endometrial lesions were found and uterine abnormalities. However, because of the high cost
treated. Leona returned for acupuncture treatment and of MRI scans and their limited availability, it is not rou-
conceived a month later. tinely offered.42
® In this case, it was acceptable to try acupuncture and
natural conception for three to four cycles because
laparoscopy is very invasive and has procedural risks. Endometrial biopsy
However, once it became clear that natural conception Endometrial biopsy should only be used to investigate
was unlikely, further investigations were appropriate. strongly suspected specific endometrial pathology, such
as neoplasia or chronic endometritis.3 It is no longer indi-
cated for evaluating luteal function or dating the
Fluoroscopic/hysteroscopic selective tubal endometrium.3
cannulation
Fluoroscopic/hysteroscopic selective tubal cannulation can
Chlamydia Antibody Test
be carried out to confirm or exclude proximal tubal pathol-
ogy previously suggested by HSG or laparoscopy with The presence of antibodies to Chlamydia trachomatis has
chromotubation.3 been associated with tubal disease.3 CAT is a good nonin-
vasive alternative to HSG. However, CAT is not as sensitive
as laparoscopy.3 If the CAT is normal, the likelihood of
Hysteroscopy tubal obstruction is reduced to approximately 8%.12 An
abnormal result warrants laparoscopy.12
Hysteroscopy is a direct and definitive method of assessing
intrauterine pathology. A hysteroscope (long, thin, lighted
telescope) is inserted through the cervix into the uterus. Gas
Genetic screening
or special fluids are then infused into the uterus. As a result,
the uterine walls are stretched, allowing for good visual Peripheral karyotyping should be done as part of infertility
examination of the uterine cavity. As with many uterine investigations or prior to ART treatment in women with
assessment methods, hysteroscopy is usually done soon amenorrhoea (primary and secondary, including prema-
after menstruation so the uterine cavity can be more easily ture ovarian failure), oligomenorrhoea with hypergonado-
assessed. A directed biopsy can be done during the proce- tropism, and in apparently healthy women who have failed
dure, and therapeutic correction of certain pathologies to conceive after 1 year.45
can also be undertaken.42 Antibiotics may be prescribed Maternal balanced translocation, maternal mosaic for
afterward to reduce the risk of infection. numeric aberration, and maternal inversion are the most
When compared with transvaginal ultrasonography (a common anomalies identified by peripheral karyotyping
first-line noninvasive uterine cavity assessment), hysteros- in patients with recurrent miscarriages.46 Balanced struc-
copy has been shown to detect up to 19% more abnormal tural chromosomal abnormalities and Robertsonian trans-
findings that were missed by an ultrasound.43 Hysteros- locations are identified in 2–5% of repeated miscarriages.47
copy can detect such abnormalities as cervical stenosis, Peripheral karyotyping is therefore recommended in
endocervicitis, endocervical polyp, uterine cavity hypopla- patients with repeated miscarriages.45,47 Tests for repeated
sia, uterine septum, intrauterine adhesions, intrauterine miscarriages are described in more detail in Chapter 12.
82
Orthodox medical tests and investigations Chapter |4|
83
Acupuncture for IVF and Assisted Reproduction
linked to APS. However, they are not included in the diag- • Protein C levels (functional assay)
nostic criteria because of nonstandardized testing. • Protein S levels (functional or free level)
• Antithrombin III (functional assay)
CLINICAL TIPS • Factor V Leiden (PCR)
• Prothrombin Gene Mutation (20210A) (PCR)
ANTIPHOSPHOLIPID SYNDROME (APS) • Protein Z
Patients with APS often have headaches or migraines, Other genetic mutations have been linked to pregnancy
flashing lights in the eyes, memory problems (foggy brain), complications, but the evidence for these is weaker:54
and balance problems.64 About a fifth of patients have a
mottled skin condition called livedo reticularis, described as
• Homocysteine
‘a red or blue blotchy, lacy pattern usually on the knees,
• Other FV mutations
thighs, and upper arms’, which can be more pronounced in • Thrombomodulin gene variants
cold weather.65 • PAI-1 activity levels
Therefore, if patients present with this type of pattern, it • PAI-1 4G/4G polymorphism
may be justifiable to screen for APS, even if they do not meet • MTHFR C677T
any other criteria for tests. • Factor evaluation (VII, VIII, IX, XI)
In addition, it is advisable to assess the platelet count
as a screen for thrombocytosis and myeloproliferative
Diagnostic tests for genetic or inherited
disorders.54
thrombophilia
There are numerous genetic clotting mutations, but not all
have been linked to reproductive health issues. The follow-
Treatment
ing tests should be included in a basic inherited thrombo- If diagnosed, treatment of thrombophilia usually consists of
philia screening battery because the evidence of these a combination of anticoagulation medication, such as low
genetic clotting mutations’ involvement is strong:54 molecular weight heparin administered subcutaneously
84
Orthodox medical tests and investigations Chapter |4|
85
Acupuncture for IVF and Assisted Reproduction
Table 4.7 Associations between some microbiological agents and anatomical location of female infertility66
Bacteria
C. trachomatis Definite Definite Definite and very common
Neisseria gonorrhoeae Definite, but less studied Definite Definite
Mycoplasma hominis Probable Possible Still to be defined
Ureaplasma urealyticum Probable Possible Still to be defined
Mycoplasma genitalium Probable Possible Most probable
Bacteria associated with Possible Possible Probable; no associations with
vaginosis specific organisms
Escherichia coli Doubtful Possible Possible
Yeastsx
Candida spp. Doubtful Doubtful Highly improbable
Protozoa
Trichomonas vaginalis Possible cofactor Doubtful Possible cofactor
Viruses
Human papilloma virus Defined through cervical Defined through cervical Improbable
intraepithelial neoplasia intraepithelial neoplasia
Herpes simplex virus Doubtful Doubtful Association needs further
investigation
subfertility is defined ‘by abnormal semen parameters but a semen sample can be collected usually by masturbation
may be present even when the semen analysis is normal’.4 into a special container or by intercourse into a special con-
The aim of male factor subfertility investigation is to iden- dom.4 The semen sample needs to be examined in the lab-
tify the cause of abnormal semen and any underlying med- oratory within an hour of collection.4 WHO interpretation
ical condition.4 Chapter 8 discusses male factor infertility of semen analysis is provided in Table 4.8.
in greater detail. The finding of an abnormal semen analysis result should
be followed up by another semen analysis, ideally 3 months
CLINICAL TIPS later to allow sufficient time for new sperm to be formed.5
However, if no sperm is found in the initial sample or there
MALE FACTOR INVESTIGATIONS is an extremely low sperm concentration, a repeat semen
If a male partner already has a child, it does not exclude the analysis should be performed as soon as possible.5
possibility of newly acquired secondary subfertility.4 Following two or more abnormal semen analyses or in
Therefore, male infertility investigations should still be cases with unexplained subfertility, additional assessment
undertaken. by a urologist and additional tests are indicated.4 Addi-
Confirmed male factor does not exclude presence of a tional tests may include:4
concomitant female factor; therefore, a female partner
• Serial semen analyses
should still be evaluated.
• Endocrine evaluation
• Postejaculatory urinalysis
Semen analysis • Ultrasound scan
• Specialized semen and sperm tests, such as sperm
Semen analysis is the most fundamental part of the assess- antibodies tests and sperm DNA fragmentation tests
ment of male factor subfertility. After 2–5 days of abstinence, • Genetic screening
86
Orthodox medical tests and investigations Chapter |4|
Endocrine investigations
CLINICAL TIPS An endocrine investigation is recommended for men with:
TESTS AND INVESTIGATIONS: SEMEN ANALYSIS • Abnormal semen parameters (especially if
concentration is 10 mil/mL)4,74
Semen analysis results can be affected by many factors,
• Impaired sexual function4
including medication, period of abstinence, and fever in the
3 months preceding the test. • Other clinical findings suggesting hormonal
involvement4
87
Acupuncture for IVF and Assisted Reproduction
88
Orthodox medical tests and investigations Chapter |4|
numbers both white blood cells and immature germ cells. MSOME
Truly raised white blood cells (>1 million leukocytes per
mL), also referred to as pyospermia, may indicate genital In addition to standard semen analysis, an advanced sperm
tract infection or inflammation.4 A number of tests are examination method called Motile Sperm Organelles Mor-
available to help differentiate between immature germ cells phology Examination (MSOME) can be undertaken.76 It is
and white blood cells. a newer method of sperm examination that is done under
high magnification (6,000 ).77 It can pick up morpho-
logical sperm abnormalities, which standard semen analy-
Antisperm antibodies tests sis may miss.
Antisperm antibodies (ASA) can form when the immune Among other factors examined, the individual spermato-
system is exposed to large quantities of sperm through a zoon’s nucleus is checked to see if its shape is smooth, sym-
breach of the blood-testes barrier,4 for example, following metric, and oval with an average length and width
trauma, torsion, biopsy, and vasectomy (the latter being estimated to be around 4.75 0.20 and 3.28 0.20 mm,
the most common cause seen in the authors’ practices). respectively.77 The chromatin mass, acrosome, and tail
Once formed, ASA can affect the motility of sperm and are also checked.77 MSOME is commonly used with the
its interaction with the egg.75 Intracytoplasmic Morphologically Selected Sperm Injec-
As ASA rarely causes male subfertility, and ICSI success- tion fertilization method (see Chapter 6).
fully overcomes ASA problems, ASA tests are not recom-
mended as part of routine screening.4,5
Sperm DNA fragmentation tests
Semen parameters (as measured by basic semen testing) do
Case study not directly correlate with fertility. One of the explanations
is that sperm may have damaged DNA, which semen anal-
Tests and Investigations: ASA ysis does not detect.78 DNA fragmentation is commonly
detected in the sperm of subfertile men.79 DNA damage
Jessica came to the clinic for acupuncture treatment to help
her and her husband, Mat, conceive. Mat had one child has been linked to reduced rates of natural conception80
from a previous relationship. and conception through Intrauterine Insemination,80
They had already tried to conceive for 9 months. After IVF,80–82 and, to a lesser extent, ICSI.80,81 DNA fragmenta-
3 months of acupuncture treatment and no conception, tion of the ejaculate is potentially a better marker of male
Jessica and Mat were advised to see their doctor and have fertility.83 DNA damage can occur:79
some tests. • During spermatogenesis
The tests revealed that Mat’s semen contained ASA. Mat • During sperm maturation
had had a vasectomy while he was in a previous relationship • By apoptosis or
and had later undergone vasectomy reversal. However, ASA • As a result of oxidative stress
formed as a result of the procedure.
Jessica and Mat needed IVF treatment. There are different types of sperm DNA integrity tests, the
most common being Sperm Chromatin Structural Assay
89
Acupuncture for IVF and Assisted Reproduction
Type of Findings Interpretation and develop. They were advised to undergo further
test comments investigations before attempting any more IVF, including
the SCSA sperm DNA fragmentation test.
SCSA 27% DNA Unlikely to result in
The SCSA result showed 32% damage. Ryan was advised
damage85 pregnancy
about how he could minimize further damage to his
TUNEL >36.5% DNA Significantly lower sperm DNA.
damage82 pregnancy rates On their next IVF cycle, Ryan and Emma conceived twins.
COMET >50% DNA Significantly lower live-
damage86 birth rates
Genetic screening
25–50% DNA Reduced live-birth rates
damage86 Genetic abnormalities can affect spermatogenesis or sperm
transport. Men with nonobstructive azoospermia (absence
of sperm in semen) and severe oligospermia (sperm con-
(SCSA), terminal deoxynucleotidyl transferase dUTP nick centration of <5 mil/mL) are particularly at risk of genetic
end labelling (TUNEL) assay, and the single-cell gel electro- abnormalities and, therefore, should undergo genetic
phoresis (Comet) assay.4,84 Table 4.12 provides threshold screening.4,45 Patients in whom genetic abnormalities are
values for DNA fragmentation tests. detected may need genetic counselling prior to IVF.
ASRM does not recommend routine DNA fragmentation
testing because treatment options are very limited and the Cystic fibrosis gene mutation
prognostic value is questionable.4,87 However, DNA testing
may be useful in cases of unexplained infertility because it The cystic fibrosis transmembrane conductance regulator
is estimated that as many as 40% of these cases may be (CFTR) gene is so strongly associated with CBAVD that
related to sperm DNA damage.88 ASRM recommends that all men with CBAVD should be
From the TCM point of view, syndromes linked to sperm assumed to have a CFTR gene mutation.4 The CFTR muta-
DNA fragmentation may include: tion is also common in men with azoospermia (absence of
sperm in semen) because of congenital bilateral obstruc-
• Kidney Jing (Essence) Deficiency tion of the epididymides and in men with unilateral con-
• Yin Deficiency genital absence of the vas deferens.4 Therefore, these men
• Yang Deficiency should be offered genetic testing.
• Qi Deficiency
• Blood Deficiency
• Heat/Fire Karyotyping
Chromosomal abnormalities in men can lead to a higher
incidence of miscarriages and chromosomal abnormalities
INTERESTING FACTS of children. The prevalence of chromosomal abnormalities
is inversely proportionally related to sperm count; these
SPERM DNA DAMAGE abnormalities are more common in men with no sperm
There is evidence that eggs may repair the DNA damage in and very rare in men with normal sperm concentrations.4
sperm. However, in eggs that are compromised (for The most common chromosomal abnormalities are sex
example, in women of advanced reproductive age), this chromosomal aneuploidy (Klinefelter syndrome; 47,XXY)
function may be less efficient.78 and structural autosomal abnormalities.4,89
ASRM recommends that all men with nonobstructive
azoospermia (absence of sperm in semen) or severe oligos-
permia (sperm concentration of <5 mil/mL) should have
high-resolution karyotyping evaluation before undergoing
Case study ART45 or ICSI.4
90
Orthodox medical tests and investigations Chapter |4|
<5 mil/mL).4 Karyotyping cannot detect this abnormality, Some of these tests are listed here for information
but polymerase chain reaction techniques can be used purposes only.
instead. The degree and location of the deletion will affect
the success of ART, even with ICSI. Sons of men with
Y-chromosome microdeletions will inherit the abnormality. Sperm Penetration Assay/Hamster Egg
ASRM recommends that Y-chromosome analysis should Penetration Test
be offered to all men with nonobstructive azoospermia
(absence of sperm in semen) or severe oligospermia (sperm Sperm Penetration Assay, also known as the Hamster Egg
concentration of <5 mil/mL) before undergoing ICSI.4 Penetration Test, looks at the ability of sperm to penetrate
a zona-free hamster egg. This test was originally developed
in 1976. Despite its very good predictive value for fertiliza-
Infection screening tion, it is not widely used because it is expensive and
technically demanding.79 Tests results depend on the expe-
Infections can affect the male reproductive tract and poten-
rience of the laboratory carrying out the test.90 ASRM does
tially lead to blockage and infection affecting the semen.66
not recommend the routine use of these tests because ICSI
Many infections are asymptomatic. Therefore, it may be pru-
is widely adopted in male factor patients, and, therefore,
dent to rule out infections before ART treatment is started.
the sperm’s ability to penetrate the egg is less relevant.4
Microbiological agents, which affect male fertility, are
summarized in Table 4.13.
Hemizona Assay
Other tests
Hemizona Assay (HZA) is a test developed in 1988 that
Other advanced tests have been developed, particularly in examines sperm’s ability to bind to the zona pellucida of
research settings, but they have limited clinical applications. a human egg. Many IVF cycles are believed to fail because
Table 4.13 Associations between some microbiological agents and male infertility66
Bacteria
C. trachomatis Definite Doubtful Possible
N. gonorrhoeae Definite Probable Probable
M. hominis Doubtful Doubtful Doubtful
U. urealyticum Doubtful Doubtful Doubtful
M. genitalium Doubtful Doubtful Attaches to human sperm
Bacteria associated Doubtful Doubtful Doubtful
with vaginosis
E. coli Definite, common Definite, common Possible
Yeasts
Candida spp. Doubtful Doubtful Rare cases
Protozoa
T. vaginalis Doubtful Doubtful Probable under specific conditions
Viruses
Human papilloma virus Doubtful Doubtful Association needs further
investigations
Herpes simplex virus Doubtful Doubtful Probable
91
Acupuncture for IVF and Assisted Reproduction
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intracytoplasmic sperm injection. et al. Thrombophilia in pregnancy: a 72. Thonneau P, Marchand S, Tallec A,
Fertil Steril 2000;74:94–6. systematic review. Br J Haematol et al. Incidence and main causes of
50. Papanikolaou EG, Vernaeve V, 2006;132:171–96. infertility in a resident population (1
Kolibianakis E, et al. Is chromosome 62. McNamee K, Dawood F, 850 000) of three French regions
analysis mandatory in the initial Farquharson RG. Thrombophilia (1988–1989)*. Hum Reprod
investigation of normovulatory and early pregnancy loss. Best Pract 1991;6:811–6.
women seeking infertility treatment? Res Clin Obstet Gynaecol 73. WHO. Reference values and semen
Hum Reprod 2005;20:2899–903. 2012;26:91–102. nomenclature. In: WHO Laboratory
51. Crosignani PG, Rubin BL. Optimal 63. Miyakis S, Lockshin MD, Atsumi T, Manual for the Examination and
use of infertility diagnostic tests and et al. International consensus Processing of Human Semen. 5th ed.
treatments. The ESHRE capri statement on an update of the Geneva: World Health Organization;
workshop group. Hum Reprod classification criteria for 2010. p. 223–6, Appendix 1.
2000;15:723–32. definite antiphospholipid syndrome 74. Choy JT, Ellsworth P. Overview of
52. Heit JA. Thrombophilia: common (APS). J Thromb Haemost 2006; current approaches to the evaluation
questions on laboratory assessment 4(2):295–306. and management of male infertility.
and management. Hematol Am Soc 64. About Hughes syndrome | APS | the Urol Nurs 2012;32:286–304.
Hematol Educ Program 2007;2007 brain. Available from: http://www. 75. Esteves SC, Miyaoka R, Agarwal A. An
(1):127–35. hughes-syndrome.org/about- update on the clinical assessment of
53. Baglin T, Gray E, Greaves M, et al. hughes-syndrome/brain.php#. the infertile male. Clinics
Clinical guidelines for testing for UYRdeZXS6fQ [accessed 4 May 2011;66:691–700.
heritable thrombophilia. Br J 2013]. 76. Klement AH, Koren-Morag N,
Haematol 2010;149:209–20. 65. About Hughes syndrome | APS | the Itsykson P, et al. Intracytoplasmic
54. Paidas MJ, Ku D-HW, skin. Available from: http://www. morphologically selected sperm
Langhoff-Roos J, et al. Inherited hughes-syndrome.org/about- injection versus intracytoplasmic
thrombophilias and adverse hughes-syndrome/skin.php#. sperm injection: a step toward a
pregnancy outcome: screening and UYReZZXS6fQ [accessed 4 May clinical algorithm. Fertil Steril
management. Semin Perinatol 2013]. 2013;99:1290–3.
2005;29:150–63. 66. Pellati D, Mylonakis I, Bertoloni G, 77. Oliveira JB, Petersen CG, Massaro FC,
55. Bellver J, Soares SR, Alvarez C, et al. et al. Genital tract infections and et al. Motile sperm organelle
The role of thrombophilia and infertility. Eur J Obstet Gynecol morphology examination
thyroid autoimmunity in Reprod Biol 2008;140(1):3–11. (MSOME): intervariation study of
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normal sperm and sperm with large fertilization and pregnancy. Fertil Medicine. The clinical utility of
nuclear vacuoles. Reprod Biol Steril 2004;81:965–72. sperm DNA integrity testing: a
Endocrinol 2010;8:56. 83. Barnhart KT. Epidemiology of male guideline. Fertil Steril
78. Barratt CL, Aitken RJ, Björndahl L, and female reproductive disorders 2013;99:673–7.
et al. Sperm DNA: organization, and impact on fertility regulation and 88. Bungum M. Sperm DNA, integrity
protection and vulnerability: from population growth. Fertil Steril assessment: a new tool in
basic science to clinical applications 2011;95:2200–3. diagnosis and treatment of fertility.
– a position report. Hum Reprod 84. Schulte RT, Ohl DA, Sigman M, et al. Obstet Gynecol Int
2010;25:824–38. Sperm DNA damage in male 2012;2012:531042.
79. Natali A, Turek PJ. An assessment of infertility: etiologies, assays, and 89. Esteves SC, Hamada A, Kondray V,
new sperm tests for male infertility. outcomes. J Assist Reprod Genet et al. What every gynecologist should
Urology 2011;77:1027–34. 2010;27:3–12. know about male infertility: an
80. Evenson D, Wixon R. Meta-analysis 85. Larson-Cook KL, Brannian JD, update. Arch Gynecol Obstet
of sperm DNA fragmentation using Hansen KA, et al. Relationship 2012;286:217–29.
the sperm chromatin structure assay. between the outcomes of assisted 90. Practice Committee of the American
Reprod Biomed Online reproductive techniques and sperm Society for Reproductive Medicine.
2006;12:466–72. DNA fragmentation as measured by Report on optimal evaluation of the
81. Li Z, Wang L, Cai J, et al. Correlation the sperm chromatin structure assay. infertile male. Fertil Steril 2006;86:
of sperm DNA damage with Fertil Steril 2003;80:895–902. S202–9.
IVF and ICSI outcomes: a 86. Simon L, Proutski I, Stevenson M, 91. Speroff L, Fritz MA. Sperm and egg
systematic review and meta-analysis. et al. Sperm DNA damage has a transport, fertilization, and
J Assist Reprod Genet negative association with live-birth implantation. In: Clinical
2006;23:367–76. rates after IVF. Reprod Biomed gynecologic endocrinology and
82. Henkel R, Hajimohammad M, Online 2013;26:68–78. infertility. 7th ed. Philadelphia:
Stalf T, et al. Influence of 87. The Practice Committee of the Lippincott Williams & Wilkins; 2005.
deoxyribonucleic acid damage on American Society for Reproductive p. 233–59. [chapter 7].
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Chapter |5|
Investigations from a TCM perspective
Clinical methods of diagnosis in Traditional Chinese • Patient’s contact details: address, telephone numbers,
Medicine (TCM) include looking and listening, pulse email address, etc.
examination, inspection of the tongue, abdominal exami- • Family doctor’s name and clinic
nation, and inquiry (medical history taking). These diag- • ART clinic and consultant’s name (if relevant)
nostic methods help fertility acupuncturists to diagnose • Confirmed associated co-morbid medical illnesses
and correctly manage patients before, during, and after (such as diabetes, hypertension, thyroid disease,
Assisted Reproductive Technology (ART) treatments such Polycystic Ovarian Syndrome (PCOS))
as In Vitro Fertilization (IVF). • Confirmed infertility diagnosis (if any)
For ethical and medico-legal purposes, it is useful to obtain
your patient’s and his or her partner’s signed consent
permitting you to liaise with medical professionals on their
MEDICAL AND FERTILITY HISTORY behalf.
TAKING
with regular 28-day cycles, who may have up to 13 n White, curdy, and odourless
opportunities in a year. So, in 3 years, one couple may n White/grey homogeneous coating of vaginal walls
make as many as 39 attempts, but another couple, only and vulva that has a fishy odour
9 attempts. n Yellow-green frothy discharge with fishy odour.
• Frequency and timing of intercourse (see Chapter 7).5,6 • Breast discharges in men and women may be linked to
• Length of time since stopping contraception.5 high prolactin levels and, potentially, pituitary
• Any sexual intercourse issues, such as pain or bleeding tumours; therefore, all affected patients (except
during or after the intercourse,5,6 any ejaculation or breastfeeding women) should be referred for a
erectile issues,5 low libido, relationship issues, or magnetic resonance imaging scan.19
others. In some cases, IVF may not be necessary, and, • Excessive body hair and/or acne in women could
instead, alternative methods of natural conception, indicate PCOS.20
such as self-insemination using a syringe (the ‘turkey It is important to remember that these are only indi-
baster’ method), could be tried (see Chapter 7 for more cators of possible pathology and not proof of diseases.
information). Therefore, care should be taken not to alarm your
• If the female patient produces fertile cervical mucus, patients unnecessarily when discussing these symptoms
how much, and for how many days. Many patients with them.
know about cervical mucus, but some may not.
(The significance of this is discussed in the section
on sexual intercourse in Chapter 7.) Menstrual cycle
• Lubrication usage.
• Frequency of sexual intercourse outside of the fertile Questions relating to menstrual cycles should include the
window; this is relevant because men who ejaculate on following (see the section on menstrual cycle regulation
a regular basis have healthier sperm.7,8 in Chapter 8 for details on how to use this information):
• Age at menarche.6
• Length and regularity of the menstrual cycle.6
General health • Any premenstrual symptoms, for example, breast
tenderness, changes in bowels, bloating, lower back
This is where acupuncturists enquire into every aspect of a pain, mood swings, headaches, etc.
patient’s health, including digestive, respiratory, cardiovas- • Any menstrual pain and, if so, its severity, location, and
cular, urinary, and musculoskeletal systems, energy levels, type.6 Does the patient have to take medication and if
body temperature regulation, memory and concentration, so, which one? (See Appendix VI for details on
headaches, and sleeping patterns. commonly used medications that can affect fertility.)
Some specific findings, which may necessitate further All patients with period pain should be assessed for other
Orthodox medical investigations relating to subfertility, signs of endometriosis, such as painful intercourse,
include: cycle-related bowel or urinary changes, pelvic pain
• Digestive symptoms such as pain and bloating may be outside of period, ovulation pain, etc. (see the section on
related to inflammatory bowel disease (IBD), which is endometriosis in Chapter 8 for further information).
increasingly being linked to infertility,9–11 possibly • Menses: their length, amount of blood flow (heavy
because of nutritional deficiencies caused by IBD or light), any spotting before or after menses,
absorption issues. colour, clotting, consistency (see the section on
• Thirst and frequent urination could indicate diabetes.12 menstrual cycle regulation in Chapter 8 for
• Feeling cold with low energy levels could be due to information about how to interpret these signs from
hypothyroidism,13,14 which can cause infertility and the TCM point of view).
pregnancy loss.13 • Any recent changes to cycle length or bleeding
• Feeling unusually hot could be caused by patterns. These may indicate pathology, such as early
hyperthyroidism15 or early or premature menopause, stages of menopause, systemic disease, PCOS (see
especially if accompanied by short or irregular Chapter 8).
menstrual cycles.16 • If there is any bleeding outside of menses (for example,
• Widespread joint pain may potentially indicate at ovulation time). This is considered a red flag, and
inflammation and autoimmune pathology. women should be referred to their doctor for further
• Migraines and/or problems with concentration could investigations to exclude a sinister cause of midcycle
be caused by clotting issues such as Antiphospholipid bleeding.
Syndrome,17 especially in patients who have a history • If a patient charts her Basal Body Temperature (BBT),
of miscarriages or pregnancy loss. it may be useful to review the charts (see
• Vaginal discharges may be normal or pathologic. section ‘Introduction to BBT diagnosis’ later in this
Abnormal discharge may be:18 chapter).
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Investigations from a TCM perspective Chapter |5|
Past medical history disease. A family history of diabetes may put a female
patient at higher risk of developing this disease. PCOS is
Past medical history may impact on fertility. Men should be also associated with diabetes.
asked about any history of:5
• Mumps
• Testicular trauma or torsion
• Surgery (for example, hernia or orchidopexy, Previous pregnancies and obstetric
vasectomy) history
• Undescended testis
Both partners should be asked individually if they have
• Sexually transmitted diseases (STDs)
achieved a pregnancy in the current or in previous relation-
Women should be asked about any history of:5 ships and the outcome of any pregnancies. It is important
• STDs to remember that a past history of pregnancy does not
• Pelvic inflammatory disease or infections exclude the possibility of current infertility.28 For example,
• Pelvic surgery (for example, appendicitis or it is quite common for men who have previously fathered a
ovarian cysts) child to have an abnormal semen analysis when trying for a
• Cervical conization baby with a new partner.
Cancer treatments in either partner may cause subfertility.5 The emotional impact of any previous terminations can
be evident decades later and should not be underestimated.
It is important to ask if there were any post-termination
Medical tests and investigations complications, such as infections, that may have caused
damage to the endometrial lining.
It is not unusual for patients to use phrases such as ‘all the In women with a history of miscarriage(s) or pregnancy
tests results were normal’. It is very important to request loss, it is important to find out the following:
copies of all the test results and follow up on any abnormal
• Do they know at which stage the baby stopped
or borderline results. In many cases, a referral for further developing? This may be different from when they
investigations is necessary. Sometimes errors, such as incor- started bleeding or physically miscarried the
rect timing of hormonal blood tests, can be identified. Such pregnancy. If the foetus stopped developing during the
patients should be referred for a retest. In some cases, essen- second trimester, this outcome should have triggered
tial tests may not have been conducted. For example, investigations, even if the woman had only one
patients with symptoms of thyroid disease do not always miscarriage.29 (Chapter 12 discusses miscarriages in
get tested to confirm or exclude the disease. Chapter 4 greater detail.)
provides detailed information about Orthodox medical
• If they had investigations undertaken to determine the
subfertility investigations and their interpretation. cause of the miscarriage, what were the findings?
Female patients need to confirm their rubella vaccina-
• How was the miscarriage managed: naturally,
tion status and their cervical smear history.5 medically, or surgically? Surgical curettage may have
Chapter 4 provides detailed information about tests and affected the endometrium.30
investigations. Appendix I provides a test and investigation
• Were there any circumstances that could explain the
template form. miscarriage(s), such as an infection or a physical or
emotional trauma? For example, if a miscarriage at
17 weeks was caused by physical trauma, it is likely to
Family medical history be a one-time event that will require no further
Female patients need to be asked about any history of investigations.
maternal gynaecologic and obstetric problems. This is • Were there any lifestyle-related factors that were linked
important to record because a woman tends to have the to the miscarriages (see Chapter 7)? For example, did
menopause at a similar age as her mother.6,21 Therefore, the woman take any medication that is known to
if a patient’s mother had early onset menopause, it may increase the risk of miscarriage? When asking
be prudent (if it has not already been done) to refer the questions, be very careful not make the patient feel
patient for ovarian reserve investigations. guilty or as if she is being judged by the acupuncturist
There is also some evidence that daughters of women about something she may or may not have done or
with endometriosis are at higher risk of developing endo- events that were out of her control or influence.
metriosis.22 Diabetes, PCOS,23–26 and thyroid disease27 Sometimes a referral for miscarriage investigation may be
can also have a familial link. Familial twin delivery may indicated (see the section on miscarriages in Chapter 12
also be relevant. for further information).
A maternal history of recurrent miscarriages6 may indi- In pregnancies that resulted in live birth, it is important
cate family history of thrombophilia or autoimmune to find out the following:
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Acupuncture for IVF and Assisted Reproduction
100
Investigations from a TCM perspective Chapter |5|
• Morphokinetic analysis (embryoscope, Early Embryo • Peak oestrogen level (if raised, may indicate Ovarian
Viability Assessment or EEVA™) Hyperstimulation Syndrome or OHSS (discussed in
Chapter 11) or damaged endometrial receptivity
(discussed in Chapter 12))
Pretreatment stage (usually
• Endometrial thickness and quality (see Chapter 10 for a
downregulation stage) discussion of what is considered a suboptimal
Acupuncture treatment (if it was done) endometrium)
Was acupuncture treatment administered to one or both Chapter 10 discusses in detail how to overcome obstacles
partners? If so, was it sufficient and appropriate? during ART/IVF and Chapters 8 and 9 outline methods that
may possibly improve a patient’s response to ovarian stim-
Medication protocol ulation. Chapter 6 discusses how acupuncture treatment
may enhance each stage of ART/IVF treatment.
What ART/IVF medication was prescribed, what was the
dose, and for how long was it taken?
Complications
Reaction to medication Did the patient experience any degree of OHSS (see
Chapter 11)?
Did the patient experience any reaction to the medication?
For example:
• Mood swings or emotional imbalances such as worry Ovulation induction
or anxiety
• What medication and what dose was used to ‘trigger’
• Physical side effects, commonly hot flushes, headaches,
final egg maturation?
congestion, or dryness
• Was acupuncture administered between the ‘trigger’
• Medication-induced TCM pathology (for example, of
and egg retrieval days (see Chapter 9)?
the Liver, Kidney, Stomach, and Spleen) that could
have negatively affected subsequent stages of the IVF
process (see Chapter 9) Egg retrieval
Day of egg retrieval
Ovarian stimulation phase
This helps to establish how many days of stimulation
Baseline ultrasound scan (if carried out) occurred before the patient underwent egg retrieval. In
• The number of antral follicles on each ovary (gives an some cases, egg retrieval is carried out too early or too late
idea of the patient’s follicular pool available for (for reasons of logistical convenience of the ART units).
recruitment in that cycle) Suboptimal timing of egg retrieval may result in a lower
• Thickness of the endometrium (if too thick in the number of mature eggs or a lower number of eggs being
beginning of the cycle, it may compromise the result) retrieved (see Chapter 10).
• Oestrogen levels (if raised, the patient may need to
downregulate for longer) Number and maturity of eggs at collection
• Any cysts and their sizes • How many eggs were collected?
• Is it in accordance with the number of follicles? Most
Acupuncture treatment (if it was done) follicles 15 mm should contain a mature egg.
Was acupuncture treatment administered to one or both • How many eggs were mature and suitable for
partners? If so, was it sufficient and appropriate? fertilization?
• How many eggs, if any, were matured with In Vitro
Medication protocol Maturation?
What ART/IVF medication was prescribed, what was the
dose, and for how long was it taken? Pain during egg retrieval
• What kind of anaesthesia was used?
Response to ovarian stimulation • Did the patient experience any pain during or after the
Finding out the patient’s level of response to ovarian stim- retrieval?
ulation will help to determine the extent to which acupunc-
ture treatment and management may improve the patient’s Semen parameters
response. The ways to measure ovarian response include If fresh semen was used, what were the semen parameters
finding out: that day? (See Chapter 4 for semen analysis interpretation
• How many follicles were available for aspiration on and Chapter 8 for information about male factor
each ovary and their sizes subfertility.)
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Acupuncture for IVF and Assisted Reproduction
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Investigations from a TCM perspective Chapter |5|
assured presence is an external manifestation of a healthy eyes and mouth and a fetid body odour, signs that the
Jing-Shen. Wood phase or Liver is in distress. Such a patient may have
A good time to first assess Jing-Shen is during the initial issues with fertility because of disordered functioning of
consultation, when an acupuncturist often intuitively Liver Qi, which is required for growth, regeneration, and
senses the patient’s state of Jing-Shen. While taking the case activity, thus affecting embryo development or implanta-
history, the acupuncturist can observe the patient’s eyes tion in the Uterus.
and complexion and assess whether the patient’s personal- Recommended reading for those who are interested in
ity, communications, and interactions are in accordance learning more about the Five Phases is:
with each other. For example, if a patient discusses her his- • Classical Five Element Acupuncture by John Worsley
tory of miscarriages and tells the acupuncturist that she has • Five Element Constitutional Acupuncture by Angela
accepted what happened to her, yet her eyes at that point Hicks, John Hicks, and Peter Mole
look very dull and sad, this could potentially indicate a
repressed emotion, which is a sign of pathology. The acu-
puncturist can then enquire further to ascertain the degree TCM pulse diagnosis in subfertility
of grief still present and/or blocked. On further question- Pulse examination of both wrists confirms the location of
ing, it is not unusual for a patient to open up and cry, which disorders44 and pathology of the Zang organs.45,46 The
can have a therapeutic value. Other signs to look for emotional disposition of the patient can also be identified.
include whether the patient is able to make eye contact Pulse examination is usually combined with other methods
and/or the movement patterns of the eyes. of diagnosis; however, it can be used as the sole method of
The assessment of Jing-Shen can also be used prognosti- assessment.47
cally. For example: Pulse examination provides a baseline clinical reference
• In a woman in whom Jing-Shen becomes evident of the state of health. Ongoing pulse examination helps to
following the embryo transfer procedure, this may measure acupuncture treatment progress48 and also iden-
indicate that conception is taking place, particularly if tify new clinical issues that may need the administration
Jing-Shen was not observable prior to that. of timely acupuncture treatment. This is especially
• Conversely, if, after a previous observation of Jing-Shen important during all IVF stages because IVF medications,
in a pregnant woman, there is a sudden change, such as particularly downregulation and ovarian stimulation med-
a pale, dull, lustreless complexion with dullness of the ications, may cause Qi, Yang, or Blood Deficiency, Stag-
eyes, this may coincide with the cessation of foetal nation, Dampness, and/or Fire. A new pathology initially
development and an impending pregnancy loss. may only be evident as a new pulse quality.
Pulse examination is both a diagnostic and prognostic
The Five Phases examination tool, helping to formulate the treatment principles, needle
in subfertility techniques, dose, and frequency of acupuncture treatment.
In complex cases, the predominance of an Empty or Full
The Five Phase doctrine divides Qi into Five Phases: Water, condition can be clarified. Table 5.1 lists pulse qualities
Wood, Fire, Earth, and Metal. Observation of the nature and their associated syndromes commonly found in
and the varied qualities of different types of people resulted subfertile patients.
in the generation of a system of correspondences33 between
the Spirit, emotions, tone of voice, odour, and colours of
a patient and his or her state of health. CLINICAL TIPS
Figure 5.1 summarizes all Five Phase correspondences. PULSE DIAGNOSIS IN SUBFERTILITY IN TCM
Acupuncturists can use this as one of the tools to assess CLASSICAL LITERATURE
a subfertile patient and gain a different perspective of the
® A thin pulse reading in an overweight person may
patient’s health.
indicate the presence of Cold in the Uterus.51
For example, the Kidney is associated with the spirit Zhi
® A deficient pulse reading on the right rear position
(Will) and the emotion of fear. A patient with a healthy
indicates Mingmen (Fire of Life) is weak.59
Kidney will have a strong Zhi (Will), which will enable
® In TCM classical literature, it is said that a choppy, weak,
that person to overcome fertility obstacles. Those patients
and faint pulse indicates severe infertility.51
who have a weak Zhi (Will) may give up after only one IVF
failure because they fear another failure of the treatment. ® According to Li Shi Zhen, a choppy pulse can indicate an
inability of the mother’s Blood to nourish the (embryo) or
This fear may further injure an already weak Kidney. A
foetus,49 potentially resulting in its demise. This is often
weak Kidney may also result in poor-quality eggs, sperm,
observed in patients who have Blood Deficiency or
and/or embryos, or miscarriage because Kidney Qi, Jing
patients who have diminishing ovarian reserve and/or
(Essence), Yin, and Yang are important for egg and sperm
implantation failure.
production.
® A floating and tight pulse may indicate an impending
Another example is a very angry patient who shouts when
miscarriage.51
speaking and has a green-blue (purplish) hue around the
103
Acupuncture for IVF and Assisted Reproduction
PHASE: FIRE
Reproductive Qi:
Growth, maturity,
movement, and prosperous
ZANG: HEART
Spirit: Shen
ad
ot on: S ness/joy
i
Em
s) e of voice: Talk
PHASE: WOOD Ton olour: Re ing PHASE: EARTH
s
ne
C d
Ang are
ur: Burnt
Sp
g
Reproductive Qi: Odo Reproductive Qi:
To Co : Aromatic
pu n
e
aw
irit:
Em f voice:
e: S er
Colour: Green/ outi
ne lour
Origin, growth, Nourishment,
tid l
Odour: Fe rp
O
Spirit: Hun (mental
o
o
regeneration, and activity distribution, balance,
Yi (t orry
h
do
tion
and support
ur
Emotion:
hought)
:W
c
: Yello
i
ZANG: LIVER
vo
Singing
Diagnostic ZANG: SPLEEN
of
w
indication
T o n e
h zy
To
O l
en s/g n g
w
ou
n
gt rief
W it e
Co vo
ro
r:
e o Em r
F
e s a il i
ou F
r oul ur : W
f
ic : B l a Odo r: )
o u e:
h
e c
ot : G k C ol oic n
S
it: i o n : roan
o f v S a d tr
pi
in g
Zh Fea To ne : (s
i (w r ti o n o
ill ) E m o it: P
PHASE: WATER S p ir PHASE: METAL
ZANG: KIDNEY
ZANG: LUNG
Figure 5.1 Diagnostic indications and correspondences within the Five Phase doctrine.4,34–40,42,43
104
Table 5.1 Pulse qualities commonly found in subfertile patients and differential diagnosis
Pulse Shen Jing Qi Blood Cold Damp Phlegm Heat/Fire Damp- Stagnation Yin Yang
quality (Spirit) (Essence) Deficiency Deficiency Heat or Blood Deficiency Deficiency
Deficiency Deficiency Stasis
p p p p p p p
49,50 48,51 49–51
Choppy Blood-Cold or +Cold50 48
Blood Damage
Blood Stagnation49 to Bodily
disorder52 or Fluids49
Cold-Damp48
p p p p p p
49 49,53 49,53
Deep Qi and Stasis of Qi Yin Pulse54 49
Qi and
Yang53 and Blood53 Yang53
p p p p p p
49 49
Empty Shen (Spirit) Damage Qi and Qi and Blood55 50 50
55
Deficiency, to Jing Blood, Yuan
causing fear (Essence) (Original)
or fright49 and Blood50 Qi Deficiency49
p p p p p p p p
49,50 48,49 49,50 49 48,49 49
Fine/thin The seven Caused by
Emotions49 Dampness55
p p p p p p
49 49 49
Knotted +Stagnation49 55 55
Blood and
Qi55
p p p p
49
Moving Heart and Jing Yin
Kidney (Essence) Deficiency in
Dysfunction49 Deficiency in the female49
the male49
p p p p
49 49
Overflowing Full or +Empty
Empty Fire49
Heat48
p p p
Rapid Anger47 Heat/ Yin Fluid
Fire48,54 damaged,
Empty-
Heat49
p p p p p p p
52 53 48,56
Slippery Rheum,52 Internal 49 52,56
Yang
(Floating and Heat49,56 pulse50,54
Rapid ¼ Phlegm–
Heat)48
p p p p p p
49 49 48,54 49 49 49,57,58
Slow
p p p p p p p
49 49 49 49,55 49 49
Soft Empty-
Cold49,55
p p p p p
49,50 49 49,50
Weak +Floating48 49,50 49,50
p p p p
48,49 49,56
Wiry +Rapid49 49,56
p p p
105
49 49 49
Leathery
Acupuncture for IVF and Assisted Reproduction
LUNGS
Heart
Heat/fire, Stagnation
Qi, Blood
Yin, Yang
Emotion
106
Investigations from a TCM perspective Chapter |5|
REN17
Tenderness
Qi stagnation
REN14
Tenderness
Heart dysfunction REN9
Tight, tender
Fluid disfunction
Distension, swelling Stagnation
Phlegm–Fluids
Ovarian hyperstimulation
syndrome (OHSS) Excessive hair growth
Moist
Tight
Dampness
Qi and Blood
Stagnation
Colour
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Acupuncture for IVF and Assisted Reproduction
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Investigations from a TCM perspective Chapter |5|
thorough TCM diagnosis and individualize each treatment Signs and symptoms
approach, rather than relying on a rote approach.
• Fear,83,84 for example, of childlessness
The following section provides a detailed TCM literature
• Dispirited Shen (Spirit)85–88
review of signs and symptoms associated with the most
• Premature ageing,81,85 for example, premature hair loss
common syndromes. and/or greying87,89
• Weak constitution and physical strength,85,86 low
reserves of Qi74
Kidney syndromes • Forgetfulness81,86,87,89
• Sexual and reproductive decline74,81,85,86,88,90
Kidney Jing (Essence) Deficiency
• Thin vaginal discharge87,91,92
As discussed in Chapter 2, the Kidney has an important role • Late onset of menarche85
in fertility as the basis for reproduction. The Kidney is • Amenorrhoea81,93
related to Mingmen (the Gate of Life), connecting to the • Menstrual irregularities,86,87,94–97 delayed86,94,96,98 or
Chamber of Semen in the male and the Uterus in the early menses98,99
female. Therefore, Kidney Jing (Essence) has a significant • Lower abdominal pain after menstruation94
influence over the quality of sperm, eggs, and embryos. • Spotting86
• Miscarriage(s)87,100,101
• Complexion: dull and dark85,86
Aetiology
• Lower back pain74,83,89
The Kidney stores Jing (Essence) that fluctuates in yearly • Weak legs85,86,102
cycles. The age of patients and/or their supply of Pre-Natal • Dizziness81,87
Jing (Essence) may cause constitutional tendencies that • Urination: frequent or dribbling of urine,43,86 slight
influence the quality and supply of Kidney Jing (Essence) incontinence74
in their offspring.80,81 Many couples begin trying for a baby • Pulse: leathery,49,103 weak,49,74,80,81,87,96 deep,80,81,96
at a later stage of life, when reserves of Kidney Jing fine49,87
(Essence) are in decline. In ART treatment, this can poten- • Tongue: white coating,87,96 pale,74,87 or red and peeled
tially result in failure because of egg and sperm issues. tongue body80
It is not uncommon in today’s society for people to work
hard without a balance of rest and activity. Patients can con-
sume their supply of Kidney Jing (Essence) through exces- Potential consequences for reproduction and ART
sive demanding physical or mental strain and overwork.81 • Poor ovarian reserve
Constant and prolonged fear (for example, fear of not • Poor response to ovarian stimulation (for example, low
conceiving) can also consume Kidney Jing (Essence). number of follicles, eggs, or poor-quality eggs)
An inadequate diet and irregular eating contributes to an • Abnormal sperm parameters or sperm DNA (may
earlier decline of Kidney Jing (Essence) as Post-Natal Jing require ICSI fertilization method)
(Essence) supplements and supports Pre-Natal Jing (Essence). • Low fertilization rate (due to poor-quality sperm or eggs)
• Poor embryo grades or embryos that develop
abnormally
Pathology
• Genetic abnormalities in parents or embryos
The Kidney’s interrelationship with the Zangfu is often • RIF
prevalent in subfertile patients undergoing ART. Such • Preclinical or first trimester pregnancy loss
patients often have Kidney Jing (Essence) Deficiency associ- • Potentially may result in a need for donor eggs and/
ated with Liver and Uterus Blood Deficiency along with defi- or sperm
ciencies of the Ren and Chong Mai (Conception and
Penetrating Vessels). Liver Blood and Kidney Jing (Essence)
are mutually engendering.82 Subfertile women with histo- Acupuncture treatment
ries of failed IVF caused by implantation failure after the Table 5.2 lists acupuncture points that treat Kidney Jing
transfer of seemingly good or poor-quality embryos have (Essence) Deficiency and the rationale for using them.
this dual pathology.
However, it is important to note that there are other syn-
dromes that influence Kidney Jing (Essence) and reduce
reproductive potential. For example, Kidney Jing (Essence)
Kidney Yin Deficiency
pathology can be secondary to Liver Qi Stagnation. Stagna- As discussed in Chapter 2, Yin plays a fundamental role in
tion can block Kidney Jing (Essence), reduce sperm and egg fertility because it is closely linked to the phases of the men-
quality and implantation potential, or lead to early preg- strual cycle. The Kidney is the source of Yin and Yang.92
nancy loss. Kidney Jing (Essence) Deficiency can also induce From an integrated viewpoint, Yin is responsible for the
Liver Blood Deficiency. quality of follicles, eggs, and sperm. Kidney Yin is also
109
Acupuncture for IVF and Assisted Reproduction
110
Investigations from a TCM perspective Chapter |5|
• Spotting41,98,119
• Pulse: fine and rapid55,81,88 (with Empty Heat), weak49,74 Kidney Yang Deficiency
• Tongue: red,81,87,88,97 with cracks, no coating81 or Yang Deficiency in men or women may prevent new life
patchy coating,74,87 small tongue body74 forming. As discussed in Chapter 2, Yang is the motivating
force for all physiological processes of transformation.80
Potential consequences for reproduction and ART Kidney Yang has a wide range of catalytic functions and
• Poor follicular growth and poorer quality of eggs processes and is the foundation for all the Yang energies
• Poor sperm parameters of the body. Kidney Yang warms the Uterus and is strongly
• Low fertilization rate related to the second phase of the menstrual cycle and
• Suboptimal embryo development embryonic development.
• Emotional symptoms during reproductive treatment
• RIF
Aetiology
Acupuncture treatment
The interrelationship between Kidney Jing (Essence), Yin,
Table 5.3 lists acupuncture points that treat Kidney Yin and Yang means that constitutional tendencies are associ-
Deficiency and the rationale for using them. ated with Yang Deficiency, just as they are implicated in Jing
(Essence) and Yin Deficiencies.90 Other aetiologies include:
Case study • Physical overwork may injure Kidney Yang.80
• Inappropriate sexual practices (for example, too much
Kidney Jing (Essence), Kidney Yin, Liver Blood intercourse) may weaken the Kidney.90 Chapter 7
Deficiencies, and Stagnation discusses in detail sexual practices from a TCM
perspective.
Julie, age 38, had two miscarriages at 8 and 10 weeks’
gestation and 2 years of subfertility following her last • Raw and cold foods (for example, salads and cold
miscarriage. drinks) can injure Yang.123
• Invasion by External Pathogenic Factors (EPFs) such as
Continued Cold can damage Yang.124
111
Acupuncture for IVF and Assisted Reproduction
• Miscarriage can result from Yang Deficiency92 and may Table 5.4 Kidney Yang Deficiency acupuncture
also cause or exacerbate Yang Deficiency.
treatment
• Generally, chronic illness can cause Kidney Yang
Deficiency.80
Acupuncture Rationale
• Fear and sadness, which are often seen in subfertile
patients, may deplete Kidney Yang and injure the Shen points
(Spirit). KID3 • Tonifies Kidney Yang106
KID2 • Regulates the Kidney and tonifies
Pathology
Kidney Yang104,106
Yang Deficiency can be a primary cause of subfertility.
It can also induce or exacerbate secondary pathology. DU20 • Regulates, raises,129 and warms Yang
Kidney Yang Deficiency is associated with the decline of • Tonifies Qi, calms the embryo and the
Mingmen (Fire of Life)92 and with Du Mai (Governing Ves- foetus104
sel) pathology.125 Kidney Yang Deficiency can also result REN6 • Tonifies the Kidney, fortifies Yang105
from its close associations with Yuan (Original) Qi, Jing • Tonifies and regulates Qi105
(Essence), and Yin Deficiency. Yang Deficiency can also
compromise Yin.112 DU4 • Tonifies the Kidney and Kidney Yang,
warms Yang104
Yang protects the body from EPFs. If Yang fails, EPFs can
• Benefits the embryo and foetus104
invade the body and combine with internal pathology. For
• Regulates the Du Mai (Governing
example, External Wind Cold can combine with Internal
Vessel)129
Cold from Yang Deficiency, causing Blood Deficiency in
women and Jing (Essence) Deficiency in men.48 BL23 + BL52 • Tonifies the Kidney, fortifies Yang,
Kidney Yang may also become deficient because of benefits Jing (Essence)110
Spleen, Heart, or Lung Deficiency.92 Conversely, Kidney • Warms the Uterus110 and Dan Tian
Yang Deficiency may also induce deficiency in these KID7 • Benefits the Kidney106
organs.92 For example, deficiency of Yang–Qi can affect
the Heart and Shen (Spirit).126 Subfertile patients often pre- Moxa • Warms the Kidney, strengthens
sent with dispirited Shen (Spirit). This is particularly evident Kidney Yang111
in women of advanced reproductive age (more than 40 years • Warms Yang, especially moxa on
old) who are diagnosed with Kidney Yang Deficiency. REN8105
Women’s physiology makes them prone to Damp-
ness,127 which can cause Kidney Yang Deficiency.80 • Reproductive immunology issues
• RIF
Signs and symptoms • Early and/or recurrent miscarriages
• Bright white complexion81,88,90
• Chilliness,83,114 dislike of cold weather,74,81,87,88,90 Acupuncture treatment
sensation of cold81,87,88,90
Table 5.4 lists acupuncture points that treat Kidney Yang
• Lethargy74,84
Dispirited Shen (Spirit)87,88,126 Deficiency and the rationale for using them.
•
• Low libido74,81
• Leucorrhoea43,96,98,114
• Overweight74 Case study
• Impotence81,88,90
• Lower backache87,88,114 Kidney Yang Deficiency and Jing (Essence)
• Urination: copious clear,81,88,92 scant,92,81,87,88 or Deficiency
nocturia92,87,88 Joanne, age 35, and her partner John, age 40, had a 10-year
• Pale menses,97 tissue-type menstrual clots,74 delayed history of infertility and one failed IVF cycle. All Orthodox
menses,97,128 spotting87 medical tests’ results were ‘normal’. Their GP had advised
• Pulse: slow,57,74,81,87 weak,49,81 deep81,87,121 them to keep on trying naturally. They decided to try
• Tongue: pale,74,81,88 swollen,74,88 wet,121 thin white acupuncture to help them achieve a pregnancy.
coating81,87 At the initial acupuncture consultation, John reported
that he had had a vasectomy during his first marriage. I
referred them to a local ART centre for further investigation,
Potential consequences for reproduction and ART
and it was later confirmed that he had developed sperm
• Poor sperm parameters, particularly motility antibodies.
• Low fertilization rate or total fertilization failure
112
Investigations from a TCM perspective Chapter |5|
Aetiology
Case study—cont’d
The same constitutional factors that cause Kidney Jing
(Essence) and Yin Deficiency can also influence the supply
Key Signs and Symptoms (Joanne) and quality of Liver Blood.130 This is because Kidney Jing
® Joanne: white complexion. She was lethargic and (Essence) and Liver Blood share the same source131 and
dispirited, mainly because of the long duration of Yin Deficiency can reduce Liver Blood.131
subfertility. She had a tendency to gain weight. Heavy periods may cause or advance Liver Blood Defi-
She liked to wrap up to be warm and wore thick socks ciency. Miscarriages, physical trauma, and internal bleed-
and several layers of clothing. She generally disliked ing may also lead to Blood Deficiency.
the cold weather.
Energy that is used by the Liver to ‘get through the
® Pulse: weak and deep in the right rear position day’ and nourish the body depends on an adequate bre-
® Tongue: pale body, slightly swollen akfast, lunch, and dinner. A diet lacking in nourish-
TCM Diagnosis (Joanne) ment,130 irregular meals, or dieting affects the Stomach
and Spleen and can cause Liver Blood Deficiency. This
Kidney Yang Deficiency
is because the Stomach, Spleen, and Heart are involved
First Acupuncture Point Prescription with the production of Blood. Busy lifestyles, occupa-
(Joanne) tional influences such as night shifts, or working though
BL23 + BL52, KID3, DU4, and BL15 (moxa) lunchtimes and break periods can create unhealthy
habits. These factors reduce Post-Natal Jing (Essence);
Key Signs and Symptoms (John) induce pathology of the Kidney, Stomach, and Spleen;
® John presented with complete loss of hair. He appeared and subsequently reduce Blood stored by the Liver. Liver
very timid and fearful. Blood Deficiency can result from Stomach Qi or Yin
® Pulse: weak and deep, slightly fine quality Deficiency.
® Tongue: red Emotional dysfunction that injures the Heart and Shen
Mind and Spirit may induce Liver Blood Deficiency. This
TCM Diagnosis (John) is because the Heart governs Blood, and the Liver stores
Kidney Jing (Essence) Deficiency it. Emotion may Stagnate Qi and Blood; this then reduces
Liver Blood and nourishment to the body, and these factors
First Acupuncture Point Prescription
(John) lead to Uterus Blood Deficiency.
KID3, LIV3, GB40, REN4, and HE7.
Acupuncture treatment commenced 5 months prior to
IVF/ICSI and continued throughout IVF. Joanne and John
Pathology
now have a son. Liver Qi, Blood, and Yin Deficiency may compromise the
function of the Heart.
Discussion Deficiency of Blood makes a woman more susceptible to
John had sperm antibodies, and IVF/ICSI was their invasion by EPFs, for example, Wind Cold.132 When Cold
best treatment option. However, it is likely that John’s enters the Uterus, fertility is reduced. Blood Deficiency cre-
TCM diagnosis of Jing (Essence) Deficiency and ates Qi Stagnation and Blood Stasis.132
Joanne’s TCM diagnosis of Kidney Yang Deficiency Blood (or Yin) Deficiency can cause Heat in the
would compromise the outcome. They had already Blood,133 thus potentially affecting implantation, cau-
undergone one IVF cycle, during which they only had one
sing excessive bleeding, and/or increasing the risk of
embryo available for transfer, perhaps because of their
miscarriages.
TCM pathology. Therefore, acupuncture treatment was
provided to both of them to increase the probability of
conception.
Signs and symptoms
• Dull complexion81,90,115,134
• Insomnia,88 excessive dreaming88,89,135,136
Liver syndromes • Blurred vision81,88,89,137,138
• Dull nails89,136
Liver Blood Deficiency
• Pale-red menstrual blood,90,134,138,139 scant blood
As discussed in Chapter 2, the Liver is essential for concep- flow,81,88,136 delayed114,140 or suppressed menses,141
tion. This is because the Liver has complex interrelation- amenorrhoea81,96,138
ships with key reproductive organs (the Heart, Lung, • Dizziness81,88
Kidney, the Stomach and Spleen, and the Uterus) and • Fear, agitation,39,43,137,141 crying before period83,142
the Extraordinary Vessels. • Numbness,81 for example, of limbs130
113
Acupuncture for IVF and Assisted Reproduction
• Impotence115,143
• Pulse: choppy,81,121 thin49,81,121,136 Case study
• Tongue: pale,81,121,136 especially on the Liver area130
Liver Blood Deficiency
Susan, aged 34, had a 3-year history of subfertility and two
Potential consequences for reproduction failed IVF cycles.
and ART Orthodox Medical Tests and Diagnosis
• Poor ovarian response to stimulation Basic investigations: subfertility caused by low ovarian
• Endometrial issues (for example, thin endometrium) reserve (AMH ¼ 6.4 pmol/L)
• RIF Advanced clotting disorders tests: normal
• Reproductive immunological issues Reproductive immunology: not tested on advice of her
consultant
Previous IVF History
Acupuncture treatment Two IVF cycles; in each cycle, four eggs were retrieved, two
Table 5.5 lists acupuncture points that treat Liver Blood eggs were fertilized by ICSI, and two embryos (medium and
Deficiency and the rationale for using them. poor quality) were transferred each time.
Signs and Symptoms
® Mood: grumpy. It was difficult for her to open up and
express her feelings; she pretended that she had no hope
Table 5.5 Liver Blood Deficiency acupuncture that IVF would work, yet, without fail, she attended
treatment weekly acupuncture treatments in preparation for the
next IVF cycle.
Acupuncture Rationale ® Floaters
points ® Breast tenderness
LIV8 • Invigorates Blood and benefits the ® Headaches toward the end of her period
Uterus108 ® Pulse: left positions thin, small
• Nourishes Blood and Yin108 ® Tongue: pale, sides orangey
• Benefits the Dan Tian108
Lifestyle
LIV3 • Nourishes Liver Blood and Yin108 ® Four or more cups of coffee per day
• Tonifies Qi, Jing (Essence)108
® Tired because of a busy job, long work hours
• Invigorates sperm108
• Regulates menses108 ® Nutrition: she did not like vegetables or chicken and ate
• Spreads Liver Qi, facilitates Qi and at irregular times, often missing meals.
Blood flow, calms the embryo and TCM Diagnosis
foetus104
® Liver Blood Deficiency and Liver Qi Stagnation
LIV11 • Benefits the Uterus108 ® Kidney Jing (Essence) Deficiency
• Regulates menses108
• Promotes fertility (with moxa)108 Causes
• Benefits the Dan Tian Poor diet, overwork, constitution, injury by emotion
ST36 • Regulates and tonifies Qi and Blood, First Acupuncture Point Prescription
facilitates Qi and Blood flow104
• Calms the embryo and foetus104 LIV3, LIV8, P6, HE6, ZIGONG, ST29, and KID3
• Nourishes Blood Yin109 Acupuncture treatment began 3 months prior to IVF.
• Tonifies Qi and Blood104 Susan responded better to ovarian stimulation. She had
more follicles and achieved a higher fertilization rate. Four
P6 • Invigorates Blood104 good-quality embryos reached blastocyst stage and two
• Calms the embryo and foetus104 were transferred. Unfortunately, the cycle still failed.
BL18 • Regulates, spreads Liver Qi and
Blood104 Discussion
The ART team were pleased to note a significant
BL17 • Regulates and tonifies Blood104
improvement in the quality of embryos and achieved a
Moxa • Tonifies Qi and nourishes Blood111 blastocyst-stage transfer. But they could not explain why the
114
Investigations from a TCM perspective Chapter |5|
treatment still failed. Susan and her husband may benefit Acupuncture Rationale
from advanced investigations, such as reproductive points
immunology tests or a sperm DNA fragmentation test.
LIV3 • Tonifies Liver Qi, Yang, Blood, and
From a TCM point of view, the IVF cycle failed most likely
Yin,104 thus regulating the Liver
because of the severity of Liver Blood and Kidney Jing
(Essence) Deficiency. A busy lifestyle, shift work, and poor LIV8 • Regulates and tonifies Liver Qi and
dietary habits were significant contributing factors. Blood104
LIV14 • Spreads and regulates Liver Qi108
• Invigorates Blood108
Liver Qi Stagnation
P6 • Regulates Liver Qi and invigorates
As discussed in Chapter 2, the Liver regulates the
Blood104
menstrual cycle by moving Qi and Blood.144 This promotes
• Regulates menses104
fertility. Healthy Liver Qi can optimize a woman’s response
• Calms the embryo and foetus104
to ovarian stimulation, regulate the embryo’s development,
and support the process of implantation and early ST30 • Regulates Qi in the Uterus and Lower
pregnancy. Jiao109
• Regulates the Chong Mai
(Penetrating Vessel)109
Aetiology
ST29 • Regulates menstruation104
Liver Qi Stagnation can be a consequence of emotional and • Promotes fertility104
mental disharmony,145 such as depression, anger, frustra- • Restores the Uterus’s ability to
tion, and resentment. Qi can also become stagnated as a function104
result of excessive thought, anxiety, and fear.146 Lack of • Treats impotence104
emotional regulation causes complicated disorders in
subfertility.127
Qi Stagnation (and Blood Stasis) may also result from a Potential consequences for reproduction and ART
physical trauma,145 for example, a surgical procedure. • Poor or unpredictable ovarian response to stimulation
Invasion of EPFs such as Cold can also stagnate Qi. • Poor fertilization rate
• RIF
• Reproductive immunology issues
Pathology • Preclinical or early pregnancy loss
Liver Qi Stagnation can result from a complex underlying
pathology of Spleen, Kidney, and Heart. For example,
Spleen Qi Deficiency can lead to Dampness, and this can Acupuncture treatment
cause Liver Qi Stagnation.131 Kidney Yang Deficiency can Table 5.6 lists acupuncture points that treat Liver Qi
lead to Internal Cold, and this, in turn, can result in Liver Stagnation and the rationale for using them.
Qi Stagnation.
Case study
Signs and symptoms
Liver Qi Stagnation with Blood Heat
• Moodiness,114,140 fluctuation in mental
state,93,102,137,140 irritability81 Lucy, aged 33, suffered 18 months of subfertility. She then
• Easily angered83,90,93 or supressed anger93 conceived, but the 12-week scan showed that the baby had
• Depression,81,90,147 jealously93 died. Lucy was shocked.
• Irregular menstrual cycles88,96,138,140 or delayed Orthodox Medical Diagnosis
menses,96,140 sometimes scant81 or sometimes heavy
® PCOS
menses,148 uneven flow of menstrual blood140
® Mild endometriosis
• Painful periods88,96,149
• Premenstrual breast tenderness81,136 and emotional Signs and Symptoms
tension related to menstrual cycle74 ® Complexion: dull
• Abdominal distension81,90
® Body: slender
• Pulse: wiry49,81,90
• Tongue: normal81 or red93,121 Continued
115
Acupuncture for IVF and Assisted Reproduction
116
Investigations from a TCM perspective Chapter |5|
Heart Yin and Yang, Qi, and Blood are mutually counter-
Table 5.7 Liver Blood Stasis acupuncture treatment
balancing.112,158 This means that the Yang function of the
Heart is essential for the quality and circulation of Qi and
Acupuncture Rationale Blood. Moxibustion can be used to nourish Blood and
points promote circulation in cases not complicated by Fire.
SP4 + P6 • Opens Chong Mai (Penetrating
Vessel)122 Signs and symptoms
• Regulates Blood in the Uterus156
• Disquieted Shen (Spirit),88,159 sadness, sorrow39
• Nourishes Blood156
• Benefits Jing (Essence)156
• Complexion: dull, pale,160 or pale white88
• Regulates Qi156
• Palpitations83,90,158,160
• Eliminates Blood Stasis156 • Insomnia,90,157 dream-disturbed sleep,160 or frequent
dreaming88,90
• Reduces pain156
• Amenorrhoea100,121 or delayed menses134
LIV14 • Invigorates Blood, disperses • Scant,155 pale-red menses161
masses108 • Poor memory90,160
ST29 • Regulates menses109 • Dizziness88,162
• Warms the Uterus, invigorating • Easily frightened,160 anxious,83,157 emotional
Blood109 disturbances88,163
• Restores the Uterus functions109 • Pulse: weak,49,159 fine,49,88,157,160 or choppy157
• Influences physiology associated • Tongue: pale88,90,157,159,160
with the penis109
SP8 • Invigorates Blood122
Acupuncture treatment
• Regulates menses104 Table 5.8 lists acupuncture points that treat Heart Blood
Deficiency and the rationale for using them.
KID14 • Regulates Qi and moves Blood
Stasis106
• Benefits the Uterus106 Possible consequences for reproduction and ART
• Alleviates pain106 • Low number of follicles
• Promotes fertility106 • Poor ovarian response to stimulation
SP10 • Invigorates Blood and dispels Blood • Poor egg quality
Stasis122 • Thin endometrial lining
• Cools Blood122 • Poor fertilization rate
• Benefits menses122 and the embryo • Compromised embryo development
• RIF
BL17 + BL18 • Dispels Blood Stasis110 • Reproductive immunology issues
• Cools Blood Heat110
• Invigorates Blood110
• Regulates and nourishes Liver Blood,
Case study
spreads Qi110
117
Acupuncture for IVF and Assisted Reproduction
Pathology
The syndromes Heart Qi and/or Blood Deficiency may
Table 5.8 Heart Blood Deficiency acupuncture eventually lead to Heart Yin Deficiency.101
treatment In subfertile patients, Heart and Kidney Yin Deficiency
often occur together.101 When these patterns are combined,
Acupuncture Rationale they have a significant negative impact on follicles, eggs,
points sperm, and embryos.
118
Investigations from a TCM perspective Chapter |5|
Table 5.9 Heart Yin Deficiency acupuncture treatment Table 5.10 Heart Qi Stagnation acupuncture
treatment
Acupuncture Rationale
points Acupuncture Rationale
points
HE6 • Benefits Heart Yin and regulates
Blood164 HE5 • Regulates and tonifies Heart Qi164
• Clears Heat and Fire, calms the • Calms the Shen (Spirit)164
Shen (Spirit)164 • Benefits the Uterus164
P6 • Regulates, tonifies Heart Yin104 P5+P7 • Regulates Heart Qi Stagnation165
• Clears Heat/Fire104 • Regulates the seven emotions165
• Calms the embryo and foetus104 • Benefits the Uterus165
P5 • Benefits the Uterus165 HE7 • Regulates the Heart, calms the
104 Shen (Spirit)164
HE7 • Regulates and tonifies Heart Yin
REN15 • Regulates the Heart, calms the
REN7 • Benefits Yin and the Uterus166
Shen (Spirit)164
BL15 • Nourishes the Heart110
• Calms the Shen (Spirit)110
• Clears Heart Heat and Fire110 • Disturbed Heart and Shen (Spirit)74
• Cools Blood Heat104 • Palpitations74
• Insomnia74
• Pulse: choppy or tight, thready74
Acupuncture treatment
• Tongue: may have a red tip74
Table 5.9 lists acupuncture points that treat Heart Yin
Deficiency and the rationale for using them. Possible consequences for reproduction and ART
• Imbalance of hormones (for example, FSH or
Heart Qi Stagnation Luteinizing Hormone (LH))74
• Low oestrogen levels74
As discussed in Chapter 2, Shen (Spirit) is acquired when
the body, Heart, and Mind are settled, calm, and ‘properly • RIF
aligned’.167 A healthy Heart promotes and generates the
Shen (Spirit) and revitalizes the Uterus. A good flow of
Acupuncture treatment
Heart Qi positively influences the Shen, Mind, and Spirit, Table 5.10 lists acupuncture points that treat Heart Qi Stag-
the menstrual cycle, the egg, sperm, fertilization, the nation and the rationale for using them.
embryo’s Qi, and conception.
Aetiology
Spleen and Stomach syndromes
Worry and sadness can affect the Qi aspect of the Shen Spleen Qi Deficiency
(Spirit). Heart Qi Stagnation can arise when the mind As discussed in Chapter 2, the Spleen plays an important
and emotional disposition of a patient restrict the normal role in fertility because it is the source of Qi and Blood.
flow of Qi.146 The Spleen influences the quality of sperm and eggs
through Post-Natal Jing (Essence). Spleen Qi’s main func-
Pathology tion after embryo transfer is the transformation and
Heart Qi Stagnation can compromise the flow and vitality movement of fluids and nutrients to supply nutrition to
of Jing (Essence), Qi, and Blood, influencing the well-being the embryo.
of the patient. Heart Qi invigorates and governs the circu-
lation of Qi–Blood in the Uterus. Stagnation of Heart Qi Aetiology
can lead to Qi circulation issues in the Uterus, for example, Spleen Qi Deficiency is caused by overexertion, poor die-
in the case of amenorrhoea.74 tary habits, and/or emotional imbalances.61
Irregular eating,155 consuming cold or raw foods and
Signs and symptoms drinks, skipping meals, not eating enough, or overeating
• Chronic anxiety, agitation74 all weaken Spleen Qi.168
• Sudden shock or emotional upset74 Overthinking, worrying, or feeling anxious can lead to
• Anovulation or amenorrhoea74 mental strain and harm Spleen Qi.155
119
Acupuncture for IVF and Assisted Reproduction
Pathology
Acupuncture Rationale
Spleen Qi Deficiency may arise from Stomach Qi Defi- points
ciency95 and Lung Qi Deficiency because these organs are
closely linked. Conversely, Spleen Qi Deficiency may affect REN12 • Regulates and tonifies Spleen Qi104
these organs. Therefore, it is important to assess the Lung • Regulates Stomach Qi and Yin104
and Stomach in patients who have been diagnosed with • Benefits the embryo and foetus104
Spleen Qi Deficiency. Signs of Lung and/or Stomach SP3 • Regulates Stomach and Spleen Qi104
Deficiencies may be evident only in the reading of the • Strengthens the Spleen104
pulse. Spleen Qi Deficiency can also cause Stagnation.158 • Regulates the Lower Jiao104
ST36 • Regulates Stomach and Spleen Qi104
Signs and symptoms • Tonifies Spleen Qi and Blood (with
• Complexion: yellow83,90,169 moxa)104
• Tiredness,88,170 lassitude84,169,170 • Assists the flow of Qi and Blood104
• Loose stools84,88,90,169,170 • Benefits the embryo and foetus104
• Bearing down sensation in the lower abdomen133 SP1 • Regulates and tonifies the Spleen107
• Poor digestion,84,88 abdominal discomfort169 • Stops uterine bleeding (with
• Reduced appetite84,90 moxa)122
• Early menses, prolonged bleeding,133 heavy menstrual • Facilitates the flow of Blood104
flow,121,133 midcycle spotting • Regulates the Shen (Spirit) and
• Prolapse of the Uterus121 emotion (resulting from Heart
• Pulse: empty,55,121,169 soft,55,88 fine,55 slow96,170 dysfunction)122
• Tongue: pale88,169 or normal colour,168 may be slightly
swollen,90,121 tooth-marked edges96 BL20+BL21 • Tonifies Spleen Qi110
• Raises Spleen Qi110
• Holds Blood110
Possible consequences for reproduction and ART • Regulates the Stomach110
• RIF • Supports Pre-Natal Jing (Essence)
• Early pregnancy loss
120
Investigations from a TCM perspective Chapter |5|
121
Acupuncture for IVF and Assisted Reproduction
Acupuncture treatment
Signs and symptoms Table 5.13 lists acupuncture points that treat Phlegm–
• Copious white vaginal discharge161 Damp and the rationale for using them.
• Menstrual irregularities,161 for example,
amenorrhoea97
• Scant menstrual flow,100 thick or mucous menses74
• Overweight97,161 and/or tendency for weight gain74 Case study
• Congestion97
• Reduced appetite176 Phlegm–Damp–Cold and Blood Stasis
• Dizziness97,161 Rebecca, aged 33, had a history of one miscarriage
• Fatigue,176 sleepiness, desire to lay down146 and subsequently 2 years of subfertility. She had
• Palpitations97 PCOS and was offered Intra-Uterine Insemination (IUI) as a
• Diarrhoea146 first-line ART treatment, but she needed to lose weight
• Pulse: soft,49,177 slippery,176 sinking–slippery,49 before starting fertility treatment.
slippery full,74 wiry49,53
Tongue: thick, greasy coating74,177
Menses
•
® Very irregular: only three periods in a year
® Dull backache and stabbing abdominal pain during
a period
Table 5.13 Phlegm–Damp acupuncture treatment ® Heavy blood flow, big clots
122
Investigations from a TCM perspective Chapter |5|
Empty Cold can arise from Yang Deficiency,124 particularly DU4 • Warms Cold104
Kidney Yang. Conversely, Cold can damage Yang, causing
REN8 with moxa • Warms Yang105
Yang Deficiency.180 Yang Deficiency may allow the inva- • Disperses Cold105
sion of External Cold, thus further complicating the • Promotes fertility105
Empty/Full Cold condition.
Cold often combines with Dampness. Cold–Damp Moxa is indicated
causes Stagnation of Yang–Qi, which causes Cold in the
flesh of the Uterus.124 This occurs because the normal flow
of Qi and Blood is prevented.
• Poor egg quality
It is not uncommon to have mixed Hot/Cold conditions
• Low fertilization rates
in subfertile patients. This commonly results from the emo-
• Poor embryo development
tional consequence of subfertility generating Heat from the
• RIF
Heart or Liver, whilst Cold remains in the Uterus (a type of
• Reproductive immunology
’Heat above and Cold below’ syndrome).
• Compromises the environment of the Uterus and
embryonic development
Cold can transform into Heat disorders48,181 and cause
Stagnation or Blood Stasis.124
Acupuncture treatment
Table 5.14 lists acupuncture points that treat Internal Cold
Signs and symptoms
and the rationale for using them.
• Complexion: dark white124 or pale121
• Chilliness, aversion to Cold, cold limbs124,150
• Desire for warm drinks124 Case study
• Pale urine124,150
• Clear and thin vaginal discharge150 Cold–Coolness
• Delayed cycle,182 painful periods,121,124 dull or Julia suffered 3 years of unexplained subfertility and was
gripping-type period pain, better with warmth124 undergoing her first cycle of IVF. Her consultant decided to
• Dark clots121,124 (if Full Cold), pale-red menstrual fertilize half of her eggs by ICSI and the other half by
blood133 conventional IVF. With IVF, none of the eggs fertilized. ICSI
• Constricted,124 scant menses121 resulted in the fertilization of three embryos. Two embryos
• Pulse: tight and slow121,124,176 were transferred on day 3 and resulted in conception and
• Tongue: white tongue coating,124,176 bluish-purple121 live birth.
or pale121,176 tongue body
TCM Diagnosis
Possible consequences for reproduction and ART Cold, Coolness mainly because the tongue body was
light blue
• Hardening of egg’s zona pellucida
• Poor semen parameters Continued
123
Acupuncture for IVF and Assisted Reproduction
124
Investigations from a TCM perspective Chapter |5|
125
Acupuncture for IVF and Assisted Reproduction
126
Table 5.17 Advantages and disadvantages of BBT charting in ART acupuncture practice
Advantages Disadvantages
• Simple and cheap to administer • Can take a minimum of two or three menstrual cycles to
• Can help to confirm the diagnosis identify patterns
• May provide a TCM diagnosis that may not be available • Patients may find it too stressful to take and record their
through other methods temperature daily because they forget to do it and also
• May help to monitor treatment progress because they become anxious in response to every minor
• Helps record and monitor other observations, such as temperature fluctuation
cervical mucus secretions, timing and frequency of • Patients’ partners may also dislike this technique because
intercourse, etc. they may be awoken daily by a thermometer beeping
• Can be very accurate if used correctly and if factors that • BBT may not be very accurate because it can be affected by
could affect the temperature are logged many factors, such as poor sleep, alcohol intake, fever,
• May be useful for monitoring early pregnancy, especially medication, or poor charting techniques
in patients with a history of miscarriages • It may be difficult for an inexperienced practitioner to
• Provides different information than hormonal blood tests identify patterns
because BBT provides a day-by-day account of hormonal • It takes a lot of consultation time to review the latest BBT
balance whereas blood tests provide a snapshot of logs and give patients feedback
hormones on a given day • It can take a lot of the practitioner’s time to train patients in
correct BBT charting techniques
• BBT charting is not highly regarded in conventional medical
practice.
STEP 2
• Estimate if there is sufficient time for a patient to chart before the beginning
of ART treatment (minimum of 2–3 menstrual cycles).
STEP 3
• Assess patient's suitability and willingness to do BBT charting.
• Assess patient's partner's agreeableness to BBT charting.
STEP 4
• Train your patient in correct BBT charting techniques.
• Check that the patient has understood and remembered the techniques.
• Keep re-assessing if BBT charting is putting too much pressure on your patient.
STEP 5
• Review TCM diagnosis as soon as BBT pattern emerges and modify treatment
principles if appropriate.
• Consider if a referral to another practitioner is necessary, for example, to an
endocrinologist, if the temperature looks very abnormal.
127
Acupuncture for IVF and Assisted Reproduction
The aim is to analyse BBT patterns and compare these BBT pathology during the ovulatory phase
with the Traditional Chinese Medicine diagnosis.
Multiple markers of ovulation have more reliability than
As already mentioned, BBT can be affected by bedroom
individual markers.188 BBT charts as a method of predicting
temperature, alcohol and food ingestion, and emotional
ovulation have proven to be an inadequate tool.189,195
state.189 Illness (especially febrile) can also affect the tem-
Urinary measures of ovulation such as LH detection kits
perature. Therefore, these factors need to be excluded if the
show more reliability than BBT charts.196 One study found
BBT looks abnormal. It is important to exercise extreme
that only 34% of gynaecologists were able to predict ovula-
caution when using BBT charts to decide if a woman ovu-
tion from BBT charts; however, 80% were able to retrospec-
lates because there are some women who ovulate, but, for
tively correctly interpret the presence or absence of
some reason, this is not reflected in their basal temperature.
ovulatory cycles.197 Based on this, it is a reasonable pre-
sumption that couples and acupuncturists may also struggle
to correctly predict ovulation from BBT charts. However,
BBT pathology during the follicular phase BBT charting is useful in retrospectively determining
whether a woman has ovulated.198 Therefore, BBT charts
There are six main types of BBT abnormalities during the
may help to determine whether an ovulatory cycle occurred
follicular phase:
but not as a prospective predictor of ovulation.
• Temperature is too low (see Table 5.18) Usually, but not always, ovulatory BBT charts will have
• Temperature is too high (see Table 5.19) what is referred to as a biphasic pattern. This means that
• Phase is too long (see Table 5.20) the temperature immediately after ovulation will rise by
• Phase is too short (see Table 5.21) approximately 0.4–0.5 C (up to 1 F) and will remain at
• Temperature is unstable (see Table 5.22) that level throughout most of the luteal phase, only drop-
• Temperature is initially too high (see Table 5.23) ping 1–2 days before menstruation.190 The rise in BBT indi-
cates a successful transformation from Yin to Yang.190
It is important to note that some women can still ovulate
INTERESTING FACTS without a clear rise in luteal temperature; this is called a
FOLLICULAR PHASE BBT monophasic pattern (Table 5.24).195,199 Whilst this is consid-
ered normal from an Orthodox medical point of view, for
® A follicular phase shorter than 12 days is associated with fertility acupuncturists, a monophasic pattern may be a
miscarriages.194 Therefore, it is important to regulate pathological finding. For example, it could indicate Kidney
the follicular phase of the menstrual cycle to as close to Yang or Yin Deficiency.187
14 days as possible.
A low point on a BBT chart, referred to as thermal nadir,
® Longer duration of oral contraceptive use and recent use can occur 1 or 2 days before ovulation. Professionals and
(within 90 days) correlates with a longer follicular patients sometimes mistakenly believe that the presence
phase.194
of a thermal nadir confirms ovulation. However, its
128
Investigations from a TCM perspective Chapter |5|
129
Acupuncture for IVF and Assisted Reproduction
130
Investigations from a TCM perspective Chapter |5|
131
Acupuncture for IVF and Assisted Reproduction
presence or absence is not considered significant from The TCM view of the luteal phase is remarkably similar to
either conventional medicine or by TCM; although one that of conventional medicine. Once the BBT has risen by
study found that the thermal nadir occurs in 72% of nor- 0.4–0.5 C (up to 1 F), this level should preferably remain
mal cycles and in 42% of abnormal cycles.197 stable for between 11 and 14 days.190 The luteal phase BBT
should not fluctuate by more than 0.1 C (0.2 F). BBT
should only drop the day before or on the day of the period.
BBT pathology during the luteal phase Luteal phase pathology variants are ovulating early (i.e.,
having a shorter follicular phase) or possible inadequacy of
The maintenance of pregnancy requires progesterone
the luteal phase.190 Both may be pathological (i.e., Heat
production by the corpus luteum after ovulation and dur-
causing short follicular phase, or Kidney Yang Deficiency
ing the first trimester. Cycles in which conception occurs
affecting the maternal environment or the viability of the
have been shown to have a more rapid rise of progester-
embryo or both). The scale of Kidney Yang Deficiency is
one and higher midluteal oestrogen and progesterone
determined by the length of the luteal phase.190
levels when compared to cycles in which there is no
There are six types of BBT abnormalities during the luteal
conception.200
phase:
Luteal phase deficiency (temperature too unstable or too
low) has been associated with infertility, first trimester • Phase is too short (see Table 5.25)
pregnancy loss, short cycle, premenstrual spotting, exces- • Temperature is too low (see Table 5.26)
sive exercise, stress, obesity, PCOS, endometriosis, thyroid • Temperature is unstable
dysfunction, and ovarian ageing.200 Patients with evidence n Sawtooth pattern (see Table 5.27)
of luteal phase deficiency potentially need to be referred for n Saddle pattern (see Table 5.28)
conventional medical investigations to exclude more seri- • Temperature rises too slowly (see Table 5.29)
ous pathology. • Temperature drops too early (see Table 5.30)
132
Investigations from a TCM perspective Chapter |5|
Table 5.27 Luteal phase BBT pathology: too unstable (sawtooth pattern)190
Luteal phase: too unstable or sawtooth pattern
(fluctuates by ≥0.2 °C)
36.90
36.80
36.70
36.60
36.50
36.40
36.30
36.20
36.10
36.00
35.90
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28
Normal Sawtooth
133
Acupuncture for IVF and Assisted Reproduction
Table 5.28 Luteal phase BBT pathology: too unstable (saddle pattern)190
Luteal phase: too unstable or saddle pattern
(sudden drop around 1 week post ovulation)
36.80
36.70
36.60
36.50
36.40
36.30
36.20
36.10
36.00
35.90
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28
Normal Saddle
134
Investigations from a TCM perspective Chapter |5|
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Chapter |6|
The fundamentals of ART
• CC n Retrograde ejaculation9
9
• Follicle-Stimulating Hormone (FSH) gonadotrophins n Anejaculation
9
• Dopamine agonist medication n Erectile dysfunction
Surgical options, such as ovarian drilling, can also be used. n Sperm antibodies (because of previous infection or
Third-party ART treatment, such as donated eggs, is indi- a vasectomy, making sperm clump together)9
cated in cases where anovulation is caused by Premature • Cervical factors (for example, mucus or cervical
Ovarian Failure (POF).4 hostility).9,10
Success rates with ovulation induction depend on the • Minimal, but not severe,11 endometriosis; IUI shortly
treatment used and causes of subfertility. after laparoscopic excision can be effective12
• Third-party reproduction (for example, donor sperm
insemination in severe male factor infertility, for a
IUI single woman or a homosexual couple, or when
IVF is not an option due to religion or personal
Overview
preference)
IUI (sometimes referred to as artificial insemination) is a
Indications for a stimulated IUI are the same as for a natural
procedure that places the partner’s or donor’s prepared
IUI, and this is recommended for patients who fail to con-
sperm into a woman’s uterus via a soft catheter around the
ceive with six rounds of natural IUI (although different
time of ovulation (Figure 6.2). IUI was developed in the
clinics may apply their own criteria).9
1940s and was one of the first successful ART techniques.
IUI is contraindicated in:13
IUI helps to increase the chances of conception by
increasing the number of sperm able to reach the egg.5 It • Women with cervical atresia
is different from IVF, where fertilization takes place in • Women with cervicitis
the laboratory. In IUI, the fertilization takes place in the • Women with endometritis or bilateral tubal
female reproductive tract.6 obstruction
Semen is produced by masturbation or ejaculated into a • Most cases of amenorrhoea
special condom following coitus. Semen samples are col- • Men with severe oligospermia
lected a few hours before the scheduled time of insemina- The pregnancy rate with natural IUI is about 8% per cycle,9
tion.7 Alternatively, previously frozen sperm can be used. with CC about 7% per cycle, and with gonadotrophin stim-
The sperm is washed, and the seminal fluid is removed.8 ulation about 12% per cycle.13
IUI can be done in a spontaneous (natural) cycle or as part
of a stimulated (medicated) cycle. In a stimulated cycle, the
ovaries are stimulated with gonadotrophins, CC, or other
antioestrogens. This increases the number of eggs ovulated IVF
in that cycle from just one to either two or three.9 IVF is an ART procedure that involves fertilization of an egg
Indications for IUI in a natural cycle are: by sperm in a laboratory dish (Figure 6.2).14
• Unexplained subfertility7,9 As discussed in Chapter 2, in a natural reproductive cycle,
• Male factor subfertility several ovarian follicles are recruited each month. The body
n Low sperm count10 but must have a minimum of produces FSH, which is sufficient for only one follicle
one million motile spermatozoa9 to grow and develop. Hence, only the strongest follicle
144
The fundamentals of ART Chapter |6|
Egg collection
Ovary
Embryo
Sperm
Uterus
Egg
Embryo
Transfer
(a)
Injected sperm
Washed
sperm
(b)
Figure 6.2 Comparisons of (a) IVF and (b) IUI.
145
Acupuncture for IVF and Assisted Reproduction
survives and releases a mature egg in the process called ovu- was used, the pregnancy rate was a little higher at 33%.17
lation (Table 6.1). Live birth rates per egg retrieval were 21.5% in IVF cycles
Originally, the main indication for IVF was blockage of and 18.4 in IVF–ICSI cycles.17 Worldwide, a similar live
the fallopian tubes. Now IVF is used to treat many other birth rate of 20.2% per egg retrieval was reported in 2004
causes of subfertility (also see Table 6.2): by 52 countries and 2,184 clinics.18 Data also show that
• Tubal pathology15,16 success rates continue to rise every year.17
• Unexplained subfertility15,16 Many factors can affect the success rate of IVF (see the sec-
• Endometriosis15,16 tion ‘Repeated Implantation Failure’ in Chapter 12).
• Cervical factors15 Patients often have an expectation that they will conceive
• Uterine factors16 after just one IVF cycle. However, research shows that some
• Immunological infertility (for example, autosperm women (especially those over the age of 35) require more
antibodies in man’s sperm, presence of sperm than one treatment cycle before they conceive, sometimes
antibodies in the female partner’s mucus)15,16 up to 10 cycles of treatment.19
• Hormonal disorders (including ovulation
dysfunction)15,16
Frozen Embryo Transfer
• Male factor (by Intracytoplasmic Sperm Injection
(ICSI))15,16 In an FET, previously frozen embryos are thawed and trans-
• Age-related subfertility (for example, Diminished ferred into the uterus. Embryos can be frozen (cryopre-
Ovarian Reserve)15,16 served) at the pronuclear (one cell), cleavage (2–10
• Donor treatment15,16 cells), or blastocyst stage. The first successful pregnancy
• Other reasons (chromosomal abnormalities, cancer after FET was reported in 1983.20 Worldwide data from
chemotherapy, serious illnesses)16 52 countries showed that, in 2004, FET represented 31%
• When other ART techniques fail15 of all initiated IVF cycles.18
The European Society of Human Reproduction and Embry- Reasons for cryopreservation of embryos include:
ology data from 32 European countries, 998 clinics, • Surplus of embryos from fresh IVF cycle15
117,318 IVF cycles, and 232,844 ICSI cycles performed • Unexpected complications or findings in a fresh IVF
in 2006 found an IVF clinical pregnancy rate of 32.4% cycle that need to be resolved before embryos can be
per embryo transfer. If the ICSI fertilization technique transferred (for example, Ovarian Hyperstimulation
146
The fundamentals of ART Chapter |6|
Table 6.2 Indications for IVF and how IVF helps to overcome them
Syndrome (OHSS), poor endometrial development, eggs are retrieved from nonstimulated or minimally stimu-
uterine polyps) lated ovaries and are then matured and fertilized in vitro (in
• Fertility preservation (for example, in oncology the laboratory). The fertilized embryos are then transferred
patients) into the uterus and/or cryopreserved.
FET cycles can be done with or without hormonal prepara- The first attempts at IVM were reported by Edwards et al.
tion of the endometrium. Uncontrolled (natural) FET is in the 1960s. However, it was not until the 1980s when the
only suitable for patients with regular ovulatory cycles. first baby was born following stimulated IVM and as late as
Pregnancy rates are similar in different protocols.21 Euro- the 1990s following a nonstimulated IVM.22
pean data from 32 countries on ART treatments carried Indications for IVM include:
out in 2006 showed FET pregnancy rates as 19.1% and live • Poor responses to ovarian stimulation. For example, in
birth rates as 12.7% per thawing.17 Worldwide data for 52 women diagnosed with ovarian resistance to FSH (also
countries showed that, in 2004, FET live birth rates were known as ovary resistant syndrome) who may present
16.6% per egg retrieval.18 with amenorrhoea and a menopausal range of FSH but
It is important to note that cryopreservation techniques have normal antral follicle count (AFC) and Anti-
have improved over the last few years. The section Müllerian Hormone (AMH) levels. These women are
‘Repeated Implantation Failure’ in Chapter 12 discusses often misdiagnosed with POF.23
how FET may potentially be preferable in certain patient • Fertility preservation (for example, in patients
groups compared to fresh IVF cycles. undergoing cancer treatment or women wishing to
reduce the risk of subfertility due to endometriosis).23
• Women at risk of OHSS (for example, patients with
Polycystic Ovary Syndrome (PCOS) or Polycystic
IVM
Ovaries (PCO)).24
In IVF, eggs develop and mature under the influence of • Women diagnosed with hormonally sensitive tumours
gonadotrophin stimulation in vivo (inside the female body) or other contraindications for prolonged elevations of
and are retrieved already matured. During IVM, immature oestrogen levels.24
147
Acupuncture for IVF and Assisted Reproduction
Implantation rates following IVM range from 5.5% to Average pregnancy rates per embryo transfer are 42% in
21.6% and are lower compared to IVF.24 IVM is still classed ZIFT–ICSI cycles and are 37% in ZIFT–non-ICSI cycles.27
as an experimental treatment and is only recommended in
research settings.24
Third-party ART
There are two main types of third-party ART treatment: One
GIFT type is where a couple uses donor eggs and/or sperm or
GIFT is a technique where gametes (an egg and sperm) are embryos; the second involves the use of a surrogate to carry
transferred into a woman’s fallopian tubes via a laparoscopic the foetus.
procedure. This technique was first introduced in the 1980s
and seemed to show promise for unexplained infertility. Donor ART
GIFT accounts for <1% of ART procedures in the United
States.25 It requires at least one healthy fallopian tube and Donor ART is indicated in couples that have problems with
is not suitable in severe male factor infertility.26 Some cou- their eggs and/or sperm. Donor ART is very tightly regu-
ples choose GIFT for religious or moral reasons because the lated. Donors must undergo extensive medical and genetic
egg is not fertilized outside the body. However, this is a screening. Donated sperm is frozen and quarantined for
drawback of GIFT because fertilization cannot be con- 6 months and retested for the AIDS virus. Eggs, however,
firmed. Sometimes, surplus eggs are fertilized in the lab do not freeze as well, and the same AIDS virus screening
for subsequent freezing.26 If there is a good rate of fertiliza- is not possible in donated eggs. Donors can be financially
tion in the lab eggs, then fertilization is also assumed to compensated for their donation with varied national legis-
have taken place in the fallopian tubes. However, a success- lation relating to this. There is generally a shortage of egg
ful pregnancy is the only definitive proof. donors. In the United Kingdom, a ‘share’ scheme exists
Indications for GIFT include:26 where egg recipients pay for their donor’s IVF treatment
in return for half of the donor’s eggs. Some couples choose
• Pelvic adhesions unrelated to pelvic inflammatory their own donor. Often, the donor is a friend or a relative.
disease
Egg donors have to undergo ovarian stimulation and egg
• Endometriosis
retrieval as in standard IVF. The donated eggs are then
• Cervical factor infertility
fertilized with the recipient’s partner’s or donor’s sperm.
• Oligoanovulatory infertility
Concurrently, the recipient’s uterus is prepared to receive
• Unexplained infertility
the fertilized embryos.
• Religious or social reasons
Egg donation IVF accounts for nearly 10% of all ART
Contraindications for GIFT include:26 cycles in the United States. Its overall success rate is very
• Pelvic inflammatory disease high at about 50%.25
• Tubal infertility Because the child will not be genetically related to one or
• Severe male factor infertility both members of the couple, it can thus be a very difficult
• Contraindications for laparoscopy decision for a couple to make. There are also complex
Success rates of GIFT vary, depending on the underlying legislative issues relating to anonymity of donors. Donor
causes of subfertility and the patient’s age, with average ART is usually reserved as a procedure of last resort. However,
pregnancy rates per embryo transfer about 30%.27 for some couples, it is the only way to have a baby. All
involved parties must undergo psychological counselling
before starting the treatment. As acupuncturists, we are likely
ZIFT to treat a small proportion of the recipients and donors.
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The fundamentals of ART Chapter |6|
149
Acupuncture for IVF and Assisted Reproduction
is secreted in a pulsatile manner, synthetic agonists have a predictor of pregnancy than ovarian reserve.39 Another
constant pharmacokinetic action.28 After a period of about study analysed data from 44,437 day 3 embryo transfers
10 days, the pituitary gland is desensitized, resulting in and found that poor-quality embryos resulted in fewer
reduced FSH and LH production, which in turn stops conceptions, irrespective of maternal age.40
undesired ovulation. Agonists are usually administered as
a nasal spray or via injection.
Antagonists also supress FSH and LH production, but Embryo-grading principles
unlike agonists, they do so without the initial stimula-
tion.28 Antagonists are usually injected. Different clinics use different grading methods. The basic
The benefits of using agonists or antagonists are the principles of grading are the same; these principles are:
subject of much research and debate. GnRH analogues • Embryos should have the correct number of
are discussed further in Chapters 9 and 12. blastomeres (cells) that correspond to the day of their
development, and
• Embryos should have as little fragmentation as
Luteal/endometrial support possible.
medication Developing cleavage-stage embryos should normally
Progestogens are commonly used to support the luteal divide every 18–20 h. Slower or faster division may signify
phase of IVF cycles and in early pregnancy. They are avail- metabolic and/or chromosomal defects.41
able as a gel, pessaries, or injections,31 and they can be used Fragmentation is defined as ‘splintering, and consists of
alone or in combination with oestrogen.32 Progestogens particles of a blastomere that is falling apart’.15 It is consid-
are the most commonly used and the most effective form ered to be an essential parameter when scoring embryos.41
of luteal supplementation.33 The fragmentation of embryos is associated with their
Oestrogen can also be prescribed to promote the growth necrosis and apoptosis.42
of the endometrial lining, for example, during the follicular The degree of fragmentation is classified into mild, mod-
phase of FET. erate, and severe:41
Other luteal support medications include hCG and • Mild: <10%
GnRH agonists. However, hCG is linked to an increased • Moderate: 10–25%
risk of OHSS, and, therefore, most fertility clinics avoid • Severe: >25%
using it.33
In their review, Prados et al. concluded that severe frag-
mentation is associated with implantation failure, reduced
Other medications blastocyst formation, and reduced pregnancy rates.
A minor amount of fragmentation may have no negative
In some patients, blood-thinning medication (antiplatelets influence.41
and anticoagulation drugs such as aspirin, Clexane, and
Lovenox) are prescribed as part of IVF treatment. Such med-
ication is commonly prescribed in women who have been Cleavage-stage embryo scoring
diagnosed with thrombophilia disorders34 or empirically systems
in patients with Repeated Implantation Failure35 or
repeated miscarriages. Several scoring systems exist, and different clinics adopt
Contraceptive pills can be used to help PCOS patients different systems. At a 2010 workshop in Istanbul, mem-
regulate their cycle prior to IVF.36 They can also be used bers reached a consensus on embryo grading. It is expected
to alter the timing of a woman’s menstrual cycle in such that this grading system will be adopted by most IVF
a way that it suits the clinic’s logistical needs with respect laboratories worldwide.
to scheduling the patient’s treatments.37 The Istanbul consensus workshop established the fol-
lowing schedule for optimal cleavage rates:43
• Day 2 (44 1 h): four cells
EMBRYO GRADING • Day 3 (68 1 h): eight cells
Prados et al. concluded that transfers of embryos on day 2
with four cells and day 3 embryos with eight cells result in
Importance of embryo grading
better implantation rates and fewer miscarriages. If the first
The quality of the embryo is the best predictor of pregnancy division happens before 26 1 h in ICSI and by 28 1 h in
in IVF.38 One study analysed 1000 IVF embryo transfers IVF, better numbers and quality of blastocysts and higher
and found that women with a low AFC (1–5 follicles) were pregnancy rates result.41 Another parameter related to cell
able to achieve pregnancy at high rates with good embryos, division is that regularly shaped blastomeres (cells) also
suggesting that the quality of embryos may be a better result in increased pregnancy outcome.41
150
The fundamentals of ART Chapter |6|
Figure 6.3 Day 2 embryos: (a) poor quality and (b) good quality.
Courtesy of Care Fertility, Nottingham, UK
151
Figure 6.4 Day 3 embryos: (a) poor quality and (b) good quality.
Courtesy of Care Fertility, Nottingham, UK
Alpha Scientists in Reproductive Medicine and ESHRE Special Interest Group of Embryology. The Istanbul consensus workshop on embryo
assessment: proceedings of an expert meeting. Human Reproduction 2011;26(6):1270-83, by permission of Oxford University Press and ESHRE.
Alpha Scientists in Reproductive Medicine and ESHRE Special Interest Group of Embryology. The Istanbul Consensus Workshop on Embryo
Assessment: Proceedings of an Expert Meeting. Human Reproduction 2011;26(6):1270-83, by permission of Oxford University Press and ESHRE.
152
The fundamentals of ART Chapter |6|
Assisted hatching from the testes using Testicular Sperm Extraction (TESE)
methods.
On day 6 or 7 postfertilization44 or 72 h after the embryo In PESA, a needle is inserted into the epididymis and the
enters the uterus,45 it continually expands and contracts contents are aspirated. TESE involves cutting the testicular
and eventually breaks through the zona pellucida (its skin and extracting samples of the testes. Any extracted
shell). This process is called embryo hatching and is some- material is checked for spermatozoa. If found, spermatozoa
times referred to as the ‘first birth’. The embryo is then are then frozen to be used in IVF, usually using the ICSI fer-
ready to implant. One of the possible causes of failed IVF tilization technique (see the section ‘Intracytoplasmic
treatment is the embryo’s failure to hatch. In Assisted Sperm Injection’).50 Variations on PESA/TESE have been
Hatching (AH), on day 3, the zona is partially dissected; developed, but it is not clear which technique is more effec-
it is drilled using acidified Tyrode’s solution or piezo tech- tive.51 Figure 6.5 shows indications for each technique.
nology or thinned using laser technology.46
Evidence about the effectiveness of AH is mixed. The UK’s
National Institute for Health and Clinical Excellence ICSI
2013 guidelines do not recommend AH.47 A 2012 Cochrane In conventional IVF, fertilization is achieved by placing
review of 31 studies (1992 clinical pregnancies out of 5728) eggs in a Petri dish with 50,000–100,000 sperm. Intracyto-
concluded that AH offers a significantly increased chance of plasmic Sperm Injection (ICSI) is a fertilization technique
clinical pregnancy; however, in the studies that reported live in which an egg is fertilized by injecting a single seemingly
birth rates, results were not significant.48 intact sperm into the egg (Figure 6.6).14,52
The American Society for Reproductive Medicine does With ICSI, fertilization can be achieved regardless of
not recommend routine AH.49 However, it acknowledges sperm concentration, motility, or morphology.53 ICSI
that AH may be suitable in cases of:49 was first introduced in 1992,54 and it is now the most
• Two or more failed IVF cycles commonly used method of egg fertilization in vitro. It is
• Poor embryo quality performed in 66% of ART cycles in the United States and
• Older women ( 38 years of age) Europe.16,17
Risk factors associated with AH include possible damage to ICSI is indicated in most types of male factor infertil-
the embryo, contamination with foreign material during ity.52,54 Increasingly, ICSI is being used to treat infertility
AH, and chemical exposure.49 caused by other problems, but the evidence is mixed (see
Table 6.6).
Obstructive Non-obstructive
153
Acupuncture for IVF and Assisted Reproduction
Table 6.6 Indications for ICSI and the evidence for each indication
154
The fundamentals of ART Chapter |6|
been shown to alter plasma beta-endorphin levels which in mature. In the authors’ experience, administering acupunc-
turn can affect the hypothalamic–pituitary–adrenal (HPA) ture treatment between the trigger injection and the egg
axis by altering the release of hypothalamic GnRH and retrieval procedure helps with the final egg maturation,
pituitary gonadotrophin secretion’.64 and, therefore, more mature eggs can potentially be
retrieved. This has been noted by other authors.63
Role of acupuncture at key stages
of ART The ART/IVF treatment cycle: Egg retrieval
In the authors’ experience, acupuncture treatment helps at Research suggests that acupuncture can be used as an effec-
every stage of the ART treatment process. tive pain-relieving method during the egg retrieval proce-
dure.69–71 However, in our experience, this may be
difficult to achieve as many ART clinics prefer to use other
Preparation phase (3–6 months before
‘conventional’ methods of pain relief.
the ART/IVF treatment cycle begins)
As described in Chapter 2, ovarian follicles take around
The ART/IVF treatment cycle: Embryo transfer
360 days to develop from their dormant stage to the
ovulatory stage. During the preparation phase, acupuncture There are numerous studies that show that acupuncture
may improve the follicular development by increasing the treatment around the time of embryo transfer helps to
blood flow to the ovaries, especially if regular acupuncture increase success rates of IVF although there are also studies
is administered in the 190 days prior to ovulation/egg that do not demonstrate this effect. In the authors’ opinion,
retrieval. administering acupuncture only at the time of embryo trans-
The preparatory phase is also a very important time for fer (as is done in majority of studies) fails to maximize the
any lifestyle modifications to be adopted by patients. Acu- effect of acupuncture at other phases of IVF treatment. The
puncturists are often the only easily accessible source of section on embryo transfer in Chapter 9 explores this topic
reliable evidence-based information on what patients can further.
do to increase their chances of conception (see Chapter 7
for further details). The ART/IVF treatment cycle: Luteal phase
During this 3- to 6-month preparation stage, acupunc- and early pregnancy
ture treatment can help to reduce the severity of pre-existing
conditions known to negatively impact ART treatment, for Stress levels are probably at their highest in patients during
example, PCOS,63 endometriosis,63 or male factor infertil- the luteal phase (the dreaded ‘2-week wait’). Therefore, acu-
ity65 (see Chapter 8 for further details). puncture and emotional support are extremely important
during this stage. In addition, in our experience, using
pregnancy-supporting acupuncture points helps to prevent
Pretreatment phase (up to 3 weeks before miscarriage.
the ART/IVF treatment cycle)
During the pretreatment phase (often referred to as down- The role of fertility acupuncturists
regulation), acupuncture can help to reduce a woman’s
The main role of fertility acupuncturists is to treat patients
stress levels and relieve some of the side effects of medica-
in preparation for, during, and after ART treatment. How-
tion. In our opinion, it may also help to recruit more folli-
ever, in contemporary subfertility acupuncture practise,
cles for the treatment cycle.
patients expect more from their acupuncturists.
Emotional support
The ART/IVF treatment cycle: Ovulation
As discussed in Chapter 7, fertility patients are under
trigger and final egg maturation immense pressure and experience high stress levels during
When women inject the ‘trigger’ medication, this forces the ART treatment. Acupuncturists can help to reduce patients’
follicles to grow further and the eggs within them to stress levels by offering emotional support, not just through
155
Acupuncture for IVF and Assisted Reproduction
156
The fundamentals of ART Chapter |6|
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Itsykson P, et al. Intracytoplasmic 66. Ho M, Huang LC, Chang YY, et al. cryopreservation: a guideline. Fertil
morphologically selected sperm Electroacupuncture reduces uterine Steril 2013;99:37–43.
injection versus intracytoplasmic artery blood flow impedance in 74. Cobo A, Diaz C. Clinical application
sperm injection: a step toward a infertile women. Taiwan J Obstet of oocyte vitrification: a systematic
clinical algorithm. Fertil Steril Gynecol 2009;48:148–51. review and meta-analysis of
2013;99:1290–3. 67. Stener-Victorin E, Waldenström U, randomized controlled trials. Fertil
58. Wilding M, Coppola G, di Matteo L, Andersson SA, et al. Reduction of Steril 2011;96:277–85.
et al. Intracytoplasmic injection of blood flow impedance in the uterine 75. Cil AP, Bang H, Oktay K. Age-specific
morphologically selected arteries of infertile women with probability of live birth with
spermatozoa (IMSI) improves electro-acupuncture. Hum Reprod oocyte cryopreservation: an
outcome after assisted reproduction 1996;11:1314–7. individual patient data
by deselecting physiologically poor 68. Isoyama Manca di Villahermosa D, meta-analysis. Fertil Steril 2013;100,
quality spermatozoa. J Assist Reprod Dos Santos LG, Nogueira MB, et al. 492.e3–499.e3.
Genet 2011;28:253–62. Influence of acupuncture on the 76. Paull D, Emmanuele V, Weiss KA,
59. Leandri RD, Gachet A, Pfeffer J, et al. outcomes of in vitro fertilisation et al. Nuclear genome transfer in
Is intracytoplasmic morphologically when embryo implantation has human oocytes eliminates
selected sperm injection (IMSI) failed: a prospective randomised mitochondrial DNA variants. Nature
beneficial in the first ART cycle? A 2013;493:632–7.
159
Chapter |7|
Preconception care in preparation for ART
Patients with subfertility are possibly one of the most moti- (kg/m2) and is categorized as follows (BMI table provided
vated groups of patients that acupuncturists are ever likely in Appendix III):2
to treat. They are keen to do all they can to maximize their • BMI <18.50 ¼ underweight
chances of conception. Patients with subfertility seek out • BMI 18.50–24.99 ¼ normal weight
information on anything that they consider will help them • BMI 25.00–29.99 ¼ overweight
conceive and then diligently follow through on what they • BMI 30.00 ¼ obese
consider to be helpful.
With obesity levels increasing, it has been estimated that up
However, the vast quantity of information (both good
to 50% of women of reproductive age will be in the obese
and bad) available to people trying to conceive can often
category in the near future.3 The importance of excess
become a burden to them. It is not unusual to have patients
weight as a factor in fertility was illustrated in a prospective
who initially present who take a handful of supplements
survey of 2112 consecutive pregnant women, which found
several times a day, have a very restrictive diet, and gener-
that a BMI of >25 kg/m2 significantly increased the time to
ally put their lives on hold while undergoing Assisted
conception.4
Reproductive Technology (ART) treatment.
This chapter will provide fertility acupuncturists with a
detailed evidence-based review of the most important life-
style modifications, from both an Orthodox medical per- Maternal weight and comorbidities
spective as well as from a Traditional Chinese Medicine Obesity is associated with a number of comorbidities such
(TCM) perspective, that are beneficial to patients trying as Polycystic Ovary Syndrome (PCOS), endometriosis, and
to conceive. Appendix IV provides factsheets on lifestyle fibroids, all of which are linked with subfertility.3 Obesity is
factors that affect fertility. thought to disrupt the menstrual cycle, affect ovulation,
and raise insulin levels, which in combination leads to
increased ovarian androgen production and elevated circu-
lating oestrogen levels.5 High BMI has been associated with
WEIGHT long menstrual cycles, with effects seen even in women
with BMIs of 24–25 kg/m2 and rising with each increase
in BMI.6
Maternal weight
Maternal weight and infertility
The American Society for Reproductive Medicine (ASRM)
Maternal weight and ART
states that 12% ‘of all infertility cases are a result of the Overweight women undergoing reproductive treatments
woman either weighing too little or two much’.1 The require more gonadotrophin stimulation, have a poorer
World Health Organization (WHO) classifies weight response rate, and produce fewer eggs.5 Several recent
according to Body Mass Index (BMI). BMI is calculated reviews have found evidence that maternal obesity nega-
by dividing weight by the square of the height in metres tively affects the quality of eggs.7–9 This is thought to be
from a disruption of the maternal endocrine system, and Paternal weight and ART
also through a direct effect on the developing egg.7
A study of 12,566 couples and 25,191 IVF or ICSI cycles
A meta-analysis of 33 studies and 47,976 In Vitro Fertil-
found that couples with both partners having a BMI
ization (IVF)/Intracytoplasmic Sperm Injection (ICSI)
25 kg/m2 or couples who had a combined average BMI
cycles found that a BMI 25 kg/m2 resulted in signifi-
25 kg/m2 had a significantly lower rate of live birth fol-
cantly lower clinical pregnancy and live birth rates and sig-
lowing IVF but not following ICSI.22 A smaller study of
nificantly higher miscarriage rates.10 Another analysis of
345 couples undergoing ART found a significant linear
45,163 embryo transfers found that higher BMI was signif-
reduction in clinical pregnancy and live birth rates with
icantly associated with a reduced chance of clinical preg-
increasing paternal BMI.23
nancy and live birth in women using their own eggs but
not in donor egg recipients.11 An analysis of a smaller
sample size of 4609 cycles of IVF or ICSI found that Paternal weight and miscarriages
women with BMI 30 kg/m2 had a significantly lower
chance of implantation and clinical pregnancy and a Increased paternal BMI is linked to pregnancy loss based on
60% lower chance of a live birth.12 The odds of an IVF a study of 345 couples undergoing ART.23
cycle cancellation are also higher in women with a
BMI 25 kg/m2.13
Being underweight is also detrimental for fertility. Recommendation
A study of 2362 IVF embryo transfers found that a maternal Because excess weight is detrimental to fertility and the out-
BMI of <19 kg/m2 resulted in significantly lower implanta- come of reproductive treatment, it is vital that both male
tion rates compared to a BMI of 19–28 kg/m2 (26% vs. and female patients maintain their weight within normal
40%).14 A smaller study of 465 IVF patients had similar BMI (19–24 kg/m2).24
findings, where maternal BMI 19.9 kg/m2 was associated Regular exercise (at least 30 min of moderately intense
with significantly reduced pregnancy rates compared to exercise a minimum of 3 days a week) and a low calorie diet
BMIs of 20–27.9 kg/m2 (34.8% vs. 52.3%).15 (1000–1200 kcal/day) is recommended by authoritative
bodies as a first-line treatment of obesity.5,25 However,
one study showed that men who attempted to lose weight
while undergoing IVF–ICSI had reduced success rates.26 So
Maternal weight and miscarriages overweight patients should attempt weight loss before
For women, being over- or underweight is also linked to starting ART treatments.
miscarriages. A study of 23,821 women found that BMI Some patients may need to be referred to dieticians or
<18.5 and 25 kg/m2 significantly increased the risk of weight management programmes to help them lose or gain
miscarriage.16 A meta-analysis of 16 studies concluded that weight prior to undergoing ART.
maternal BMI 25 kg/m2 significantly increased the risk of
miscarriage, even in egg donation recipients.17 Early preg-
nancy Human Chorionic Gonadotrophin (hCG) levels SMOKING
are also lower in obese women.18 Obesity has also been
linked with an increased risk of developing pregnancy com-
plications, such as gestational diabetes, hypertension, and The effects of smoking on
spontaneous abortions. Babies of obese mothers may be reproductive health
large for their gestational age, may have an open neural
tube defect, or may have congenital heart disease.19 Research shows that smoking is consistently associated
with subfertility.27 A major review of the effect of smoking
on the reproductive system found that smoking impairs
every stage of the reproductive process.28 A prospective sur-
Paternal weight vey of 2112 consecutive pregnant women showed that
when either partner smoked more than 15 cigarettes a
Paternal weight and infertility day, it significantly increased the time to conception.4
Male weight is also important for fertility. A 2012 system- Women who smoke have decreased follicular phase
atic review and meta-analysis of 21 studies (involving a length.6,29
sample of 13,077 men) concluded that being overweight ASRM reviewed the effects of smoking on reproductive
or obese significantly increased the risk of azoospermia health and found that:27
(no sperm) or oligozoospermia (low sperm concentra- • Smoking reduces female reproductive lifespan by
tion).20 An earlier meta-analysis of 31 studies did not find 1–4 years
such associations, but this study’s findings were limited as • Smoking increases the risk of ectopic pregnancies and
data from most studies could not be aggregated.21 miscarriages
162
Preconception care in preparation for ART Chapter |7|
• Smokers require almost twice as many IVF cycles as Another study that followed 18,555 women without a
nonsmokers known history of infertility for 8 years found that alcohol
• Smokers have poorer semen parameters intake was not associated with infertility when it was
A meta-analysis of 21 studies concluded that smoking by caused by ovulatory disorders.36
women undergoing ART significantly lowered the odds A study involving 39,612 pregnant women also found
of clinical pregnancy and live birth and increased the odds there was no link between low, moderate, or high alcohol
of ectopic pregnancy and spontaneous miscarriage.30 intake and how long it took to conceive. Interestingly,
Smoking by male partners also significantly reduces fer- women who reported no alcohol intake took slightly lon-
tilization rates26 and success rates of IVF and ICSI.26,31 ger to conceive compared to women who consumed 0.5–2
Exposure to second-hand smoke is detrimental to female units of alcohol per week.37
fertility.27 Drinking alcohol has been shown to affect sperm mor-
There are significant risks of birth defects as a result of phology and sperm production. The effect is more pro-
maternal smoking. Most of the baby’s developing bodily sys- nounced with increased intake.38 In a prospective survey
tems can be malformed as a result of exposure to smoke.32 of 2112 consecutive pregnant women, researchers found
that if the male partner drank more than 20 units of alco-
hol a week, it significantly increased the couple’s time to
The TCM view of smoking conception.4
Smoking injures the Qi of the Lungs and Heart, both of
which play an important role in conception. Smoking Effects of alcohol on IVF outcome
can weaken Jing (Essence) and may also cause Heat, which,
in turn, may consume Yin (see Chapter 2). Low levels of alcohol intake may reduce live birth rates fol-
lowing IVF. A prospective cohort study of 2545 couples and
4729 IVF cycles found that women who drank 4 units of
Recommendation alcohol per week while undergoing IVF reduced their odds
of live birth by 16%.39 The same study found that when
From both the Orthodox medical and TCM perspectives,
each of the partners drank 4 units of alcohol per week,
smoking causes damage to reproductive health. Therefore,
the likelihood of live birth was 21% lower compared to
both male and female patients should be encouraged to
couples in which each partner drank <4 units of alcohol
give up smoking while attempting to conceive. According
per week.39
to ASRM, the negative effects of smoking are reversed after
smoking cessation.27 The latest National Institute of Clin-
ical Excellence (NICE) guidelines recommend that both The effect of alcohol on the risk
men and women should stop smoking while attempting
to conceive.33
of miscarriages
Understanding the ART patient’s lifetime history of expo- The alcohol intake of both male and female partners in the
sure to cigarette smoke should help the fertility acupunctur- preconception period is linked to miscarriage. For example,
ist appreciate what impact there may have been upon the in a study of 430 couples and 186 pregnancies, researchers
patient’s Jing (Essence), Lungs, and Heart and the extent found that both male and female alcohol intake of 10 or
to which acupuncture treatment principles may need to more drinks per week during the week of conception signif-
be modified accordingly. icantly increased the risk of early pregnancy loss.40
In a study of 330 women with spontaneous miscarriages
and 1168 pregnant women, researchers found that con-
ALCOHOL sumption of 5 units of alcohol per week resulted in
increased risk of miscarriages.41 A larger study of 24,679
pregnant women also reported increased first trimester
The effects of alcohol on reproductive miscarriage in those women who consumed five or more
health alcoholic drinks per week.
A prospective study of 7393 women reported that drinking Drinking even low amounts of alcohol during pregnancy
2 units of alcohol per day significantly increased the risk of increases the risk of spontaneous miscarriage before
infertility.34 16 weeks gestation, according to the findings of a very large
Another study of 7760 healthy women found that infer- study of 92,719 Danish women.42
tility was not associated with alcohol intake in younger
women. However, in women older than 30, the risk of
The TCM view of alcohol
infertility was higher in women who consumed seven or
more drinks per week compared to those who consumed Alcohol is pungent, sweet, and hot in nature, may induce Heat
fewer than one.35 or Fire, and can weaken Kidney Jing (Essence),43 the Stomach,
163
Acupuncture for IVF and Assisted Reproduction
and Liver. Drinking alcohol may damage the embryo or foe- Effect on male fertility
tus.44 When planning a pregnancy, the couple is advised not
to drink alcohol as it reduces fertility.43,44 A large meta-analysis concluded that there is no strong evi-
However, in some cases, the occasional glass of wine may dence that moderate caffeine intake by men significantly
be advantageous because it invigorates Blood vessels, dis- affects their fertility.50
pels External Pathogenic Factors (EPFs), reduces tension,
and can eliminate Blood Stasis. Couples trying to conceive RECREATIONAL DRUGS
who choose to continue to have an occasional drink
should:43
• Limit the intake Orthodox medicine
• Drink a small glass of wine with food The use of recreational drugs is also strongly associated
• Drink alcohol slowly with subfertility in both men and women19 and can
• Avoid sexual intercourse when drunk as this damages increase the risk of infertility by 70%.48
Jing (Essence)45
TCM
Recommendations Recreational drug use compromises fertility and reproduc-
tive potential by depleting Jing (Essence).
On the basis of the research available, the following recom-
mendations can be made:
Recommendation
• There is very little evidence to suggest that a low intake
of alcohol reduces chances of conception. However, It is important to ask a patient if he or she is currently using
moderate and high alcohol intake has been shown to or has previously used recreational drugs. Those who are still
affect both male and female reproductive health. using recreational drugs should be encouraged to stop and
• NICE guidelines recommend that women attempting referred to appropriate supporting services. Specialist referral
to conceive should drink no more than 1–2 units of may be necessary to help patients overcome their depen-
alcohol one to two times per week, and men should dence. When planning fertility treatment for patients who
limit their intake to 3–4 units per day.46 used recreational drugs in the past, Jing (Essence) should
• NICE guidelines also recommend that people be supported in order to improve their reproductive health.
undergoing reproductive treatment (e.g., IVF) should
not drink more than 1 unit of alcohol per day because
it reduces the effectiveness of the treatment.47 MEDICATION
• The ASRM recommends that couples trying to conceive
do not exceed two drinks per day.48
Female fertility
• Alcohol intake during pregnancy should be avoided
altogether because it affects foetal health and is also Certain prescription medications are known to affect follic-
linked to miscarriages. ular rupture and ovulation and cause impairment of tubal
function, implantation, and sexual and luteal functions
(see Appendix VI for common types of medication known
to affect fertility).19
CAFFEINE Women should also take care over what medications
they take during pregnancy. For example, the use of nonas-
pirin nonsteroidal anti-inflammatory drugs or NSAIDs
Effect on female fertility (diclofenac, naproxen, celecoxib, ibuprofen, and rofe-
Women who consume more than six cups of coffee and/or coxib), even in small doses, during pregnancy is associated
tea a day have been shown to have increased time to con- with an increased risk of miscarriage.51
ception.4 A review by Homan et al. found that there is
some evidence linking caffeine consumption to miscar-
riages and stillbirths.49 NICE guidelines state that mater-
Male fertility
nal caffeine consumption reduces success rates of Certain prescription and nonprescription medications
reproductive treatment (e.g., IVF) and, therefore, caffeine may affect male reproductive functions (such as sperm
consumption should be discouraged.33 However, the production, ejaculation, and/or erectile difficulties) and
ASRM advises that 1–2 cups of caffeinated beverages a produce changes in male hormone levels and libido.19
day before or during pregnancy is not detrimental to fer- See Appendix VI for common types of medications that
tility or pregnancy.48 are known to affect fertility.
164
Preconception care in preparation for ART Chapter |7|
The negative effects of medication may be reversed when • Glycol ethers (used in paints, varnishes, thinners,
the medication is discontinued or changed to a medication printing inks, cosmetics, perfumes)
that does not affect semen parameters.19,52 • Pesticides (includes insecticides, fungicides, herbicides,
rodenticides, fumigants; exposure can arise from
consuming affected food or water)
Recommendation • Phthalates (can be found in cosmetics, perfumes, toys,
pharmaceuticals, medical devices, lubricants, and
All patients should be asked what prescription or nonpre- wood finishers)
scription medication they take. Acupuncture practitioners • Solvents (exposure occurs primarily through breathing
may not always be aware of what medications could harm contaminated air from many different sources,
reproductive functions. Therefore, practitioners may need including detergents, drugs, glues, paints, fingernail
to seek specialist advice; for example, patients could ask polish, insulation, fibreglass, food containers, carpet
their pharmacists or doctors to review their medications. backing, cleaning products, and others)
If a patient takes medication that is known to affect • Perfluorinated compounds (PFOS, PFOA)
reproductive function, he or she should be asked to see (accumulated in the environment and food chain; used
the doctor who prescribed that medication in order to dis- in making fabrics and carpets stain resistant and water
cuss possible substitution or discontinuation. repellent and used in cooking pan coating, floor polish,
and food wrap coating)
• Polybrominated diphenyl ethers (used to make
Red flag detergents, pesticides, paints; exposure mainly through
consuming water contaminated by sewage and wet-
Medication that affects reproduction weather runoff)
Acupuncturists must never tell patients to stop medications • Chlorinated hydrocarbons such as dioxins/furans,
because we are not qualified to do so. Refer them back polychlorinated biphenyls, organochlorine pesticides,
to their medical doctors for a review of their medications. pentachlorophenol (some are banned in the United
States but remain in the environment, sometimes for
decades)
• Metals such as lead, mercury, manganese, cadmium
ENVIRONMENTAL AND (found in various household products, paints, and in
the food chain (in particular, mercury is found in
OCCUPATIONAL FACTORS seafood))
(Adapted from Ref. 53, with permission from Elsevier).
Environmental factors Men are possibly affected by exposure to environ-
mental oestrogens, both at puberty and continually
Pollution can affect fertility and reproductive processes at
through their lives. Environmental oestrogen may have
different stages and in different ways. Exposure to environ-
an effect on the Hypothalamic–Pituitary Axis and sper-
mental contaminants can happen in utero, during child-
matogenesis.3 However, the current evidence is primarily
hood and adolescent developmental years (when the
based on animal models, and further investigations are
reproductive organs grow and mature), and also in adult-
warranted.54,55
hood. Certain environmental hazards are linked to sperm
Situations that increase scrotal temperature (for example,
issues, menstrual cycle irregularities, hormonal changes,
sauna use,56 sitting down for prolonged periods, hot baths,
miscarriages, foetal loss, early menopause, malformations
using a laptop computer placed on the lap) can alter sperm
of the reproductive tract, endometriosis, fibroids, altered
production and should be avoided.33,57 There is no strong
puberty, and other reproductive changes.53
evidence that tight-fitting underwear reduces male
Contaminants that have been linked to reproductive sys-
fertility.33,57
tem changes include:53
• Air pollution (carbon monoxide, lead, ground-level
ozone, particulate matter, nitrogen dioxide, and Occupational factors
sulphur dioxide)
• Bisphenol A (used to line metal food and drink cans, Some occupations have been linked to reduced fertility.
plastic baby bottles, baby pacifiers, baby toys, certain Therefore, it is important to enquire into both partners’
microwavable and reusable food and drink containers, occupations.
and other products) Male occupations most strongly associated with subferti-
• Disinfection by-products lity include:46
• Ethylene oxide (sterilant used in dental and medical • Welders, bakers, drivers, or any other occupations
practices) involving increase in scrotal temperature
165
Acupuncture for IVF and Assisted Reproduction
166
Preconception care in preparation for ART Chapter |7|
vitamin D deficiency.65,66 The guidelines state that levels of blood coagulation81 and reduces the risk of preterm
4000 IU (100 mg) per day can be taken without medical birth.81,82 It may improve egg quality and slow ovarian age-
supervision.66 ing,83 improve embryo morphology,84 and help to reduce
the risk of miscarriages.85
In the Western world and increasingly in the developing
Iodine world, people tend to have diets high in omega 6 and low
Maternal iodine intake helps with foetal neurological in omega 3. Docosahexaenoic acid (DHA) and Eicosapen-
development.19,76 It is also important for thyroid function taenoic acid (EPA) are the most beneficial types of omega 3.
because iodine is a significant component of the thyroid During pregnancy, women should consume between 200
hormones (T4 and T3).76 and 300 mg of DHA plus EPA per day.81 Oily fish (salmon,
According to WHO, 54 countries are still affected by sardines, herring, catfish, halibut, canned tuna) is particu-
iodine deficiency, even in places where food is supplemen- larly high in omega 3.81,82 Fish high in mercury (tilefish,
ted with iodized salt.76 Maternal iodine deficiency can lead shark, swordfish, king mackerel, fresh or frozen tuna steaks
to health problems, including hypothyroidism.76 Iodine (not canned), orange roughy, marlin, Spanish mackerel)
deficiency can also affect the foetus, leading to miscar- should be avoided.81 Non-fish eaters can take fish oil sup-
riages, stillbirths, congenital anomalies, increased perinatal plements with sufficiently high EPA and DHA levels; these
mortality, and endemic cretinism.76 supplements must be purified to filter out toxins.81 Cod
Therefore, it is recommended that all women who are liver oil should be avoided because it is high in vitamin
attempting to conceive or who are pregnant should take A.81 Fish that feed on algae are a rich source of omega 3;
250 mg of iodine supplement.19,77,78 They should also eat thus, algal oil supplements are an alternative source of
foods rich in iodine, such as cow’s milk, yoghurt, eggs, omega 3 for vegan patients.81
cheese, white fish, oily fish, shellfish, meat, and poultry.78
Red flag
Red flag
Omega 3 and blood-thinning medication
Iodine supplementation Patients who take blood-thinning medication (for example,
Women who have thyroid disease or take thyroid aspirin or clexane) should not increase their omega 3 intake
medication should consult their doctor before taking iodine without first checking with their doctor or nutritionist
supplements. because omega 3 can also thin the blood.86
Iodine supplements should not be taken at the same time
of the day as iron.
Selenium
Low selenium levels have been linked to recurrent preg-
Vitamin A nancy loss.77,87 Selenium substitution and treatment with
Excessive amounts of vitamin A are harmful during preg- selenomethionine has been suggested to lower thyroid
nancy.19 It is recommended that women who are trying antibody (TPO-Ab) levels in euthyroid women, which
to conceive should avoid taking vitamin A supplements are strongly linked to pregnancy loss.77,88 Brazil nuts and
and not eat foods rich in vitamin A (e.g., crustaceans and fish (yellowfin tuna, halibut, sardines) are rich sources of
liver) during the luteal phase of the menstrual cycle and selenium.89
during pregnancy.19
Vitamin E Iron
Vitamin E is a powerful antioxidant. It has been shown to Women of childbearing age are at risk of iron deficiency
improve the thickness of the endometrial lining, if taken at anaemia because of menstrual blood loss, poor diet, and
a high dose (400–500 IU/day) from day 3 of ovarian stim- pregnancies.90 Iron deficiency has been linked to ovulatory
ulation to hCG trigger.79 Foods naturally rich in vitamin E problems.91 Therefore, it is recommended that women try-
include nuts, seeds, and vegetable oils.80 ing to conceive should supplement their iron intake.91
There are two types of iron: heme and nonheme. Heme
iron is easier to absorb and is found in most meat-based
Omega 3 products (chicken liver, canned oysters, beef liver, beef, tur-
Omega 3 is a type of essential fatty acid that can only come key). Nonheme iron sources are fortified cereals, lentils,
from the diet. Omega 3 helps to reduce inflammation and and kidney beans.92
167
Acupuncture for IVF and Assisted Reproduction
168
Preconception care in preparation for ART Chapter |7|
169
Acupuncture for IVF and Assisted Reproduction
• Raspberries, blackberries, mulberries, strawberries, For example, a study of 3628 women found that intensive
grapes, cherries, dates126 exercise increases fertility in women with BMI 25 kg/m2
but decreases fertility in women with BMI below that
Foods beneficial in Qi Stagnation syndromes level.129 Women with BMI < 25 kg/m2 have slight improve-
Vinegar120 ment in fertility with moderate exercise levels.129
•
Hawthorne,44 rose44 In their paper, Homan et al., after reviewing which life-
•
Orange peel118 style factors affect reproductive health, concluded that
•
Radish leaves, turnips, mushrooms, onions120 moderate exercise is beneficial for general health and repro-
•
ductive health.49
• Basil, cumin, turmeric, bay leaf, fennel, dill seeds,
garlic, caraway seeds118 However, overexercising may cause some people’s BMI
to decrease too much, which may contribute to subfertility.
170
Preconception care in preparation for ART Chapter |7|
171
Acupuncture for IVF and Assisted Reproduction
Effects of stress on the reproductive It is likely that patients who have less emotional support
system may have more intense psychological symptoms.
Campagne believes that stress management should be
Stress affects the Hypothalamic–Pituitary–Gonadal Axis. It used as part of fertility treatment.141 Couples may need
decreases the Gonadotrophin Releasing Hormone (GnRH) support during the infertility treatment process to help
pulse amplitude. It also decreases the Luteinizing Hormone cope with their emotions and decision making.161 Pessi-
(LH) pulse amplitude through decreasing the pituitary’s mism appears to be associated with IVF treatment fail-
responsiveness to GnRH, caused by the stress hormone ure.168 Therefore, where appropriate, reducing negative
cortisol.145 Stress increases testosterone levels in both preconceptions about IVF outcome by encouraging and
men and women.146 Stress has also been shown to reduce emphasizing a pragmatically positive perception of fertility
menstrual cycle length, but it does not affect other cycle outcome may be useful.
parameters.147 Couples need to learn effective relaxation and stress
Although the mechanisms are not fully understood, management techniques. An RCT involving 100 women
there is a link between psychosocial stress (including anx- undergoing IVF found that a significantly higher propor-
iety) and testicular function and sperm quality.148–152 tion of women (52% vs. 20%) became pregnant using
A meta-analysis of 57 studies with 29,914 participants such techniques.169
found that psychological stress lowers sperm concentration A meta-analysis of 21 studies comparing psychological
and progressive motility and increases the amount of interventions in infertile patients found no significant
abnormal forms of sperm.153 effect on mental health scores, but pregnancy rates were
Stress has been shown to significantly reduce the proba- improved in patients not undergoing ART.170 Interventions
bility of natural conception.142 A meta-analysis of 31 stud- included were counselling, individual or group support
ies found a small but significant association between stress programmes, and behavioural therapy.
and reduced pregnancy rates following ART.154 Stress may Other techniques couples could try include positive
also increase the risk of miscarriages.155,156 autogenic visualization, self-hypnosis, and relaxation
exercises. Alice Domar’s book, Conquering Infertility (ISBN
0142002011), is probably the most comprehensive
Prevalence of stress in ART patients resource to help those patients who need a deeper empathic
understanding of the effects that stress, anxiety, and depres-
Reproductive treatment causes distress, with psychological
sion have on fertility.
stress cited as a common reason why couples discontinue
fertility treatments.157 The more anxious and depressed
that a woman feels before commencing IVF treatment, CLINICAL TIPS
the more likely it is that she will terminate subfertility treat- SIMPLE STEPS TO HELP REDUCE STRESS
ment after one failed cycle.158 Those undergoing infertility
AND ANXIETY IN PATIENTS
treatment can have further exacerbations of stress levels
because of financial, physical, and emotional rea- ® Explain test results so patients may better understand
sons.141,159 At the same time, patients are aware that such their situation and/or treatment.
psychological factors may not be helpful to their chances of ® Reinforce that most patients are not infertile but
conception.160 subfertile, which means, unless they have been
Women undergoing IUI or IVF have been shown to expe- diagnosed with complete sterility, they can still have
rience emotional distress,160–162 which may persist into a child.
pregnancy.163 One in three women who undergoes fertility ® Quote statistics to your patients that eventually most
treatment admits being worried about becoming pregnant; couples conceive and have babies. Between 82% and
anxiety about having treatment injections and concern 92% of couples will conceive within 12 menstrual cycles
about deterioration in the relationship with her partner of trying, and between 90% and 98% of couples will
conceive within 24 menstrual cycles of trying.171
is usually the main source of her stress.164
Women who have undergone ART to conceive and ® Explain that it can take up to 3 years for some couples to
then miscarry in the first trimester experience more stress conceive, especially older couples, who may need to keep
trying for longer.171
and emotional trauma for at least 3 months afterward
than women who have conceived naturally and who then
miscarry.165
The TCM view of stress, mind,
and emotion
Practical tips to reduce stress
Chapter 1 described how emotions may be a cause of sub-
Various approaches are used in Orthodox medicine to fertility, and Chapter 2 discussed how emotions affect the
manage patients with psychological distress.158,166,167 reproductive system from a TCM point of view.
172
Preconception care in preparation for ART Chapter |7|
The stress response can encompass a range of emotions, time in the menstrual cycle. However, research shows
including sadness, anger, frustration, and feeling out of that couples struggle to identify their fertile time.178 There-
control. Stress can weaken the Heart and Shen (Spirit).43 fore, each couple should be screened to determine if ART is
Stress affects Qi and Blood movement, creating an appropriate next step to take. If, after taking the repro-
Stagnation172 (especially during menses), so the arrival of ductive history, it is clear that the couple did not have
menstruation can be upsetting for subfertile patients. enough intercourse or did not time the intercourse cor-
Emotional disturbance impairs Kidney Jing (Essence) and rectly, they should be given information about the fertile
Yin Yang.43 Negative emotions may exacerbate existing window and different methods of detecting ovulation
syndromes43 and, therefore, subfertility. and be advised to keep trying during the preparatory stage
Regulating emotions helps to prevent physiological and of the ART treatment cycle.
pathological changes. The avoidance of emotional distur- For sterile couples, this is inappropriate advice. For
bances enhances Heart function and preserves Kidney Jing example, if there are serious issues with sperm, then no
(Essence). amount of additional sexual intercourse will result in a
Calming a patient’s Shen (Spirit) will help with the smooth pregnancy. Great care should be taken to advise couples
flow of Qi173 and Blood and will support the patient’s where the woman is of advanced reproductive age, ensur-
Jing (Essence). Acupuncturists should aim to regulate the ing that months of valuable time are not wasted trying to
Mind to nourish the Shen (Spirit)43 and Jing (Essence).45 conceive naturally when it is clear that because of the
Taking time out for hobbies and leisure activities woman’s age, the couple may require ART.
strengthens the person’s constitution and Mind,43 thus
helping to reduce stress levels. Therefore, couples should
be advised to pursue their interests and hobbies as one Fertile window and timing of intercourse
of the ways to reduce stress levels, provided that their Conception is possible if intercourse takes place during the
hobbies are not in themselves physical stressors or psycho- fertile window, beginning around 6 days before and ending
logically stress inducing. on the day of ovulation.179 During this 6-day period, a
woman produces sperm-friendly mucus. This sperm-
friendly mucus helps to nourish and support sperm inside
Research on acupuncture and stress the fallopian tubes until the egg is released.180 The length of
and/or anxiety in fertility patients the fertile window is not determined or affected by a
woman’s age.181 Men are also more sexually attracted to
The ASRM recommends that patients experiencing women who are about to ovulate, possibly in response to
infertility-related stress should try, among other things, chemical messages released by women.182,183 Women’s
acupuncture.159 behaviour also changes when they are most fertile, for
An RCT of 43 IVF female patients found that acupuncture example, they may dress more provocatively,184 consume
treatment significantly reduced anxiety symptoms in the fewer calories,185 and have increased sexual desire.186
active treatment group. Treatment consisted of 4 weekly Couples will naturally increase the frequency of their
acupuncture sessions using acupuncture points HE7, P6, intercourse during the fertile window.187
REN17, DU20, and YINTANG.174 In another observational Several studies have shown that the chance of conception
study of 15 women receiving fertility acupuncture treat- is great if intercourse takes place within 5 days of ovulation,
ment, acupuncture improved self-efficacy and psychologi- and the chance of conception is even greater if intercourse
cal coping parameters.175 A pilot study of 57 IVF/ICSI takes place within 4 days of ovulation (Figure 7.1).181
patients showed that acupuncture was associated with sig- While it is clear that frequent and well-timed intercourse
nificantly lower stress levels before and after embryo trans- helps to increase probability of conception, both clinicians
fer, and preliminary data also suggested improved and couples need to be aware that timed intercourse has
pregnancy rates.176 It has been suggested that the acupunc- been linked to stress, erectile dysfunction (in 42.8% of
ture mode of action in improving IVF outcomes works by men), and even extramarital affairs (10.7% of men).188
reducing prolactin and cortisol levels.177 Sexual stress, such as loss of sexual self-esteem, the pressure
of scheduling intercourse, and loss of enjoyment of sexual
relations, affects both men and women in similar ways.189
RELATIONSHIP AND SEXUAL ISSUES Therefore, advice on frequency and timing of sexual
intercourse should be modified to take into account the
individual circumstances of each couple.
Sexual intercourse
The next few sections apply to patients who are still trying
to conceive naturally during the preparation phase. It is
Frequency of intercourse
easy to assume that patients presenting for ART treatment Frequency of intercourse during the fertile window is impor-
will have had sufficiently frequent intercourse at the right tant. It is generally accepted that the optimal intercourse
173
Acupuncture for IVF and Assisted Reproduction
frequency for conception is once every 1–2 days.48,179 One men with male factor infertility (defined as oligozoosper-
study analysed data from 708 menstrual cycles provided mia) should not abstain for more than 1 day if they want
by 221 couples and found that the probability of conception to achieve the best possible sperm motility and morphol-
was highest with daily intercourse (37%), still good with ogy. Even after only 2 days abstinence, sperm in these men
intercourse that occurred every other day (33%), but was started to degrade. Men with normal semen parameters do
significantly lower with intercourse that took place only not appear to suffer from deterioration of sperm so soon
once a week (15%) (Figure 7.2).190 into abstinence, but should not abstain for more than
A common misconception is that frequent intercourse is 7–10 days.192
damaging to sperm. In fact, when the sperm count is high,
the hormone inhibin is released, and sperm production
slows.191 Sperm also degrades when retained in the body
Coital practices
for long periods. A large study, which assessed 9489 Many couples engage in coital rituals in the belief that
semen samples obtained from 6008 patients, found that doing so will increase their chances of conception.
35–39 years
0.40%
0.30%
0.20%
0.10%
0.00%
−8 −7 −6 −5 −4 −3 −2 −1 0 1 2
Cycle day of intercourse (day 0 is day of ovulation)
20%
15%
10%
5%
0%
Daily Every other day Once a week
Frequency of intercourse
174
Preconception care in preparation for ART Chapter |7|
175
Acupuncture for IVF and Assisted Reproduction
30%
Probability of conception
25%
20%
15%
10%
5%
0%
1 2 3 4
(dry, no (slightly moist (damp sensation, (slippery sensation,
noticeable sensation, creamy or yellow clear, stretchy
discharge, no noticeable sticky or stringy (stringy) discharge,
least fertile) discharge) discharge) most fertile)
Mucus type
176
Preconception care in preparation for ART Chapter |7|
progesterone levels following ovulation make the body Gratification of ‘sexual desires’ and/or excessive sexual
temperature rise by 0.5 F.197 While it is an effective method desire (even if no ejaculation takes place) can also consume
of confirming when ovulation has taken place, it does not Kidney Jing (Essence) and Shen (Spirit) in the male. Subfer-
predict when the fertile window begins. tile couples who engage in frequent intercourse in hopes of
BBT is affected by factors such as fever, lack of sleep, and conceiving, therefore, benefit from lifestyle (preserving
alcohol. So couples need to learn as much as they can about Mind, Spirit, and emotion) and dietary advice (supplemen-
BBT charting in order to gather accurate information. tation of Jing (Essence), Qi, and Blood). Acupuncture treat-
For acupuncturists, BBT charts may provide additional ments that support Kidney Jing (Essence), Yin Yang, Qi,
information to help them formulate the diagnosis. Chapter 5 and Blood are also useful, especially if these are already
discusses BBT charting in greater detail. deficient. Supporting these vital substances avoids the need
to advise patients to significantly reduce their frequency of
Other methods sexual intercourse, which would reduce their potential
chances of conception.
Other ovulation detection methods used by couples
include the salivary ferning test. In this test, saliva is evalu-
ated under the microscope for signs of ferning, which is INTERESTING FACTS
associated with ovulation. However, this method is diffi-
cult to interpret.199 TESTOSTERONE IN MEN AND YANG ENERGY
Timing intercourse according to the days of the men- Interestingly, testosterone levels in men are highest in the
strual cycle is reliable in women whose menstrual cycles morning.204 From a TCM perspective, male fertility is said to
are fairly regular.197 Ovulation usually takes place 14 days fluctuate, with Yang energies rising in the morning.205
before the onset of the next menstruation. So women with
regular 28 days menstrual cycles are likely to ovulate on day
14 and their fertile phase will begin around day 9.
Recommendation
The TCM view of sexual intercourse Daily intercourse is most likely to result in conception.
Reproduction relies on a good relationship between a male Timing intercourse relative to the fertile window is
and a female partner, and coitus for the purpose of repro- necessary. The most reliable methods of ovulation detec-
duction ought to occur at a time when Blood and Qi are tion are fertile mucus days or E3G-based ovulation
strong.200 Yet, when a couple try to conceive, they need detection kits.
to have very frequent intercourse, even if they do not feel Intercourse should be fun with an emphasis on foreplay,
like it or if they are tired or ill. visual stimulation, and high and prolonged arousal. It is
Sexual intercourse is important for good physical and necessary for men to ejaculate on a regular basis even
mental well-being. Yin, Yang, Qi, Blood, and Jing (Essence) outside of the fertile window in order to reduce damage
may congeal in the absence of sexual intercourse.43 Coitus to sperm.
regulates Qi and Blood.43 Healthy sexual practice reduces
tension and supports a relationship between the couple.43
Sexual intercourse should occur when emotional well-
being is not disturbed.43 SUMMARY
Weak sexual desire and inability to enjoy sex or reach an
orgasm is related to Kidney Deficiency, in particular Kidney Treating patients in preparation for ART provides acupunc-
Yang Deficiency.201 Therefore, if patients are having difficul- turists with a unique opportunity to inform and educate
ties with their sexual relationship, the affected partner may patients about lifestyle modifications, which might signif-
benefit from strengthening his or her Kidney energy. Exces- icantly improve their chances of conception.
sive sexual desire is a result of Kidney Yin Deficiency and Being under- or overweight, smoking, drinking large
Empty-Fire Rising; nourishing Kidney Yin may be beneficial amounts of alcohol, drinking large amounts of caffeine,
in these patients.201 Excessive desire consumes Qi.45 using recreational drugs, taking certain prescriptions or
Male and female ‘sexual Essences’ are manifestations of over-the-counter medication, being exposed to environ-
Kidney Jing (Essence). Sexual ‘energy’ of the male pertains mental toxins, working in certain occupations, eating a
to Kidney Jing (Essence) and the female more to Blood. poor diet or having a deficiency in certain micronutrients,
Therefore, ejaculation is more of a direct loss of Kidney Jing exercising too much or not enough, and having high
(Essence).201 Ejaculation, age, and the health of the man levels of stress have all been shown to affect reproductive
are therefore important sexual practice considerations.202 health.
177
Acupuncture for IVF and Assisted Reproduction
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et al. Longitudinal depressive [Chapter 1]. odour is a potential cue to
symptoms and state anxiety among 174. Isoyama D, Cordts EB, ovulation. Proc Biol Sci
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183
Acupuncture for IVF and Assisted Reproduction
184
Chapter |8|
Identification and management of conditions
detrimental to IVF outcome
Conditions such as ovulatory dysfunction, tubal pathol- tubal obstruction; the accumulating fluid can leak into
ogy, endometriosis, thyroid disease, and male factor sub- the uterus and is believed to be toxic to the embryo.4
fertility reduce the chances of natural conception and
may adversely affect Assisted Reproductive Technology
(ART) treatment outcomes and/or pregnancy. Acupuncture Diagnosis
treatment in preparation for ART treatment may help to Tubal disease can be diagnosed by ultrasound, Hysterosal-
reduce the severity of these conditions and, therefore, pingography (HSG), Hysterosalpingo-contrast-ultrasonog-
increase the chances of live birth. raphy, Sonohysterography, Laparoscopy with dye, and
Fluoroscopic/hysteroscopic selective tubal cannulation.
The Chlamydia Antibody Test (CAT) checks for the pres-
ence of antibodies to Chlamydia trachomatis, which is asso-
TUBAL PATHOLOGY ciated with tubal disease. If the CAT is normal, the
likelihood of tubal obstruction is reduced to approximately
8%.5 The merits of each diagnostic technique are discussed
Overview in Chapter 4.
As described in Chapters 2 and 3, successful conception
occurs when sperm travel through the fallopian tube to
the egg and fertilize it, and then the resulting embryo
INTERESTING FACTS
travels down the fallopian tube and implants in the uterus. TUBAL BLOCKAGE
If the fallopian tube is blocked or if it hypofunctions, tubal
factor subfertility will be the result. One or both tubes can Interestingly, about 60% of patients diagnosed by HSG with
proximal tubal blockage are subsequently shown to have
be affected.
patent tubes on the next HSG6 or laparoscopy.7
HSG may have a therapeutic role, with higher pregnancy
Prevalence rates reported in the months following HSG.8
• Woman’s age and ovarian reserve In Traditional Chinese Medicine (TCM), healthy function-
• Quality and quantity of sperm ing of the fallopian tubes depends on the free movement of
• Site and extent of tubal disease Liver Qi and the moving function of Kidney Yang. Liver Qi
• Other infertility factors Stagnation leads to Blood Stasis.13,14 Deficiency of Kidney
• Risk of ectopic pregnancy Yang leads to Damp-Phlegm accumulation in the fallopian
• Patient’s preference tubes.13 Damp-Heat may be implicated in patients whose
• Success rates and cost of IVF tubal blockage is caused by infection(s).13,15 Table 8.1 lists
In the United Kingdom, the National Institute for Health acupuncture points that can be used in the treatment of
and Clinical Excellence recommends that women with mild tubal factor infertility. Chapter 5 describes TCM syn-
mild tubal disease may benefit from surgery.9 dromes in greater detail.
Hydrosalpinges
Table 8.1 Acupuncture points prescriptions for mild
Hydrosalpinx is defined as a ‘collection of watery fluid in the tubal factor infertility
uterine tube, occurring as the end-stage of pyosalpinx’.11 It
is strongly associated with reduced implantation rates.11 Syndromes Points Rationale
The fluid within the tube is believed to be toxic to the
embryo. The mechanical washout of the embryo by the Liver Qi LIV3, LIV4, Regulate Qi in the
fluid is another possible explanation for reduced implanta- Stagnation + LIV5 lateral abdomen and
tion rates.11 Laparoscopic salpingectomy (removal of the Blood Stasis the fallopian tubes15,16
affected fallopian tube(s)) prior to IVF improves IVF and Moxibustion may be
applicable if Stagnation
pregnancy outcomes.11,12
is caused by Cold
P7, P5 Calm Shen (Spirit) if
The role of the acupuncturist emotions lead to Liver
Qi Stagnation16
Acupuncture treatment Kidney Yang ST28, SP9, Resolve Damp and
As already stated, about 60% of patients diagnosed by HSG Deficiency + SP6, REN9, drain Dampness from
with proximal tubal blockage are subsequently shown to Damp-Phlegm BL32 the genital system14
have patent tubes on the next HSG6 or laparoscopy.7 There-
Damp-Heat GB41R + Regulate Dai Mai
fore, fallopian tube obstruction is not always permanent. If SJ5L + (Girdle Vessel) and
a patient wishes, a course of 3–4 months of corrective acu- GB26 resolve Damp-Heat in
puncture treatment may be attempted before IVF to the genital system14
improve patency of the fallopian tubes and, therefore,
increase the chances of natural conception. Treatment with LIV5 + LIV8 Clear Damp-Heat and
acupuncture should only be attempted if: eliminate Blood Stasis in
the Lower Jiao16
• There are no other indications for IVF (for example,
Other • Electroacupuncture: BL32 (negative
male factor subfertility).
prescriptions pole) + REN4 (positive pole)14
• Fallopian tubes have not been previously surgically
relevant for all • Acupuncture: ZIGONG + REN3,
removed (for example, following ectopic surgery).
syndromes REN14 SP12 + SP1316
• Fallopian tubes are not absent (for example, because of
• Moxibustion: REN8, REN4, REN3
an anatomical birth defect). and on the area corresponding to
• The damage to the fallopian tubes is not permanent fallopian tubes17
(such as extensive adhesions or scarring).
186
Identification and management of conditions detrimental to IVF Chapter |8|
No Yes
No After surgery
No
Conceived
187
Acupuncture for IVF and Assisted Reproduction
188
Identification and management of conditions detrimental to IVF Chapter |8|
189
Acupuncture for IVF and Assisted Reproduction
Ovulatory
disorders
Clomiphene
citrate (CC)
CC resistance CC failure
Pregnancy (no resumption (ovulation
of ovulatory resumed, but
cycles) no pregnancy)
CC + metformin LEO
or (‘ovarian drilling’)
LEO or
(‘ovarian drilling’) FSH
or gonadotrophins
FSH
gonadotrophins
190
Identification and management of conditions detrimental to IVF Chapter |8|
Effect on reproduction
Other diseases with similar presentation (for example, con-
genital adrenal hyperplasias, androgen-secreting tumours, Ovarian reserve
Cushing syndrome) should be excluded.25 The reproductive lifespan of women with PCOS can extend
Oligomenorrhoea and amenorrhoea are strong predic- on average 2 years beyond that of women with normal
tors of PCOS, and up to 90% of women with these men- ovulatory cycles.27
strual abnormalities are diagnosed with PCOS.26 Women
with oligomenorrhoea and amenorrhoea may still experi-
ence spontaneous ovulation.26 The greater the severity of Miscarriages
menstrual irregularities, the greater the severity of PCOS.26
As women with PCOS become older, their cycles become There is conflicting data on PCOS and miscarriages26,28
more regular.26 and no strong evidence that PCOS per se increases rates
Hirsutism is present in about 70% of women with PCOS of miscarriage.26,28 However, women with PCOS are often
and is a reliable marker of hyperandrogenemia although overweight or obese; this increases their risk of miscarriage
blood tests should always be carried out in all women sus- and pregnancy loss.29
pected of having PCOS.26 Acne and alopecia are not reli-
able markers of hyperandrogenemia.26
Pregnancy
Pregnant women who are diagnosed with PCOS are at risk
CLINICAL TIPS of developing gestational diabetes,26,30,31 preeclamp-
sia,26,31 and cardiovascular disease,31 which are all associ-
HIRSUTISM AND PCOS
ated with poorer pregnancy outcomes. The rate of preterm
Hirsutism is the most reliable sign of androgen excess. delivery is also higher in women with PCOS.30
However, many women with hirsutism will have had it There may be epigenetic implications for an embryo or
treated with laser treatment or may use creams or epilators foetus that develops in a high-androgen maternal environ-
to remove excess hair. Therefore, it is important to ask ment. The high circulatory levels of androgens may have an
patients if they have ever suffered from excess facial or
effect on the subsequent genetic expression of the neonate’s
abdominal hair.
reproductive and metabolic physiology when it reaches
reproductive maturity.26
There are several different phenotypes of PCOS, presenting
with various degrees of metabolic disorder, insulin resis-
Mental–emotional health
tance, menstrual cycle abnormalities, weight issues, hirsut-
ism, and subfertility.26 Women with PCOS are at an increased risk of psychological
Women with PCOS are at increased risk of developing and behavioural disorders and experience a poorer quality
diabetes. Therefore, an oral glucose tolerance test should of life.26 Therefore, the medical management of PCOS
be done in obese women with PCOS and/or women with should include psychological and behavioural therapeutic
increased visceral adiposity, as measured by waist approaches.26,32
circumference.26
191
Acupuncture for IVF and Assisted Reproduction
Lifestyle and dietary modifications Metformin may, however, have a role in prevention
of Ovarian Hyperstimulation Syndrome (OHSS). A
Many PCOS patients are overweight, which often affects
parallel, randomized, double-blind, placebo-controlled
their hormonal balance20,26 and their menstrual regularity
clinical trial concluded that metformin reduces the risk
and is associated with hyperandrogenemia and hirsut-
of OHSS by modulating the ovarian response to stimu-
ism.26 Greater abdominal or visceral adiposity is linked
lation with FSH.35
to greater insulin resistance, which exacerbates PCOS.26
Metformin should also be prescribed for PCOS women
Therefore, weight reduction through diet and exercise
with frank diabetes.26
should be a first-line approach for these patients.20,33
A 2007 ESHRE/ASRM-Sponsored PCOS Consensus
Workshop Group in Thessaloniki recommended that Surgery
obese women with PCOS should follow a hypocaloric diet
(with a 500 kcal/day deficit) with reduced glycaemic load. Surgical procedures used in the management of PCOS
If such a regimen cannot be adopted, then any calorie- include wedge resection, laparoscopic ovarian diathermy
restricted diet that achieves a 5% weight loss should or laser, and multiple ovarian puncture or ovarian dril-
be used.33 ling.33 Surgery is indicated in patients:33
A 2013 systematic review of various dietary approaches • Resistant to CC
in the management of PCOS found that no dietary • With persistently high LH levels
plan is preferable for women with PCOS. All of the inves- • Who need laparoscopic assessment for other reasons
tigated dietary plans led to improvements in pregnancy
rate, menstrual regularity, ovulation, hyperandrogenism,
insulin resistance, lipids, and quality of life.34 However, IVF
the review did find that a low glycaemic index (GI) diet IVF is only recommended in women with PCOS if all other
resulted in increased menstrual regularity compared with treatment methods fail or if they have other indications for
a ‘healthy weight loss diet’, and both low a GI diet and a IVF (for example, fallopian tube blockage, male factor
low carbohydrate diet resulted in a decrease in insulin infertility, severe endometriosis).33
resistance.34 The IVF cycle cancellation rate is higher in PCOS
Women with PCOS tend to have lower baseline patients, and the duration of stimulation is longer.36
activity levels, which further exacerbates their symp- This may be because PCOS is associated with excess weight.
tomatology. Therefore, increased physical activity is As discussed in Chapter 7, overweight women under-
recommended.33 going reproductive treatments require more gonadotro-
In our experience, some women with PCOS can have phin stimulation, have a poorer response rate, and
very low BMI. These women tend to very carefully monitor produce fewer eggs.37 Hyperandrogenism and hyperinsuli-
their weight. Some of these women may be underweight naemia may promote premature granulosa cell luteiniza-
and, therefore, may need to gain weight (see Chapter 7 tion, alter the follicular environment, and, therefore,
for recommended BMI cut off points). affect egg maturation.26
Not all women with a diagnosis of PCOS will be affected.
Many women with PCOS still produce high-quality eggs
Ovulation induction and have comparable fertilization and implantation rates
CC is the first choice treatment to induce ovulation in to those of women without PCOS.26
anovulatory women with PCOS.33 If the treatment with The rates of severe OHSS are higher in women with
CC fails, ovulation induction with gonadotrophins and PCOS (15.4%) compared to women with normal ovaries
GnRH analogues should be tried.33 These treatments were (2.7%).38 Women with PCO without PCOS are also at
discussed in detail earlier in this chapter. an increased risk of developing OHSS.39 A systematic
review found a significant and consistent relationship
between PCO and OHSS. The reviewers concluded that
Metformin interventions to moderate ART treatment are justified.40
Live birth rates per IVF cycle are similar in women with
Some research suggests that patients with PCOS may ben-
PCOS (37%) and in women with normal ovaries (40%).38
efit from metformin therapy. However, a 2012 consensus
report reviewed the evidence for the use of metformin in
women with anovulatory PCOS and found that metformin
did not enhance live birth rates or reduce pregnancy
In Vitro Maturation
complications. Therefore, its routine use is not Recently, In Vitro Maturation (IVM) has been shown to be
recommended.26 potentially a viable ART technique for PCOS patients. A
192
Identification and management of conditions detrimental to IVF Chapter |8|
prospective cohort clinical trial involving women with transfer sessions the following acupuncture points were
PCOS found improved implantation, clinical pregnancy, used: LIV3, SP10, P6, ST29, and the Shenmen auricular
and live birth rates with a single embryo transfer by the point, bilaterally. The EA group had a significantly higher
use of an optimized IVM protocol.41 number of good-quality embryos, but all other outcome
measures were comparable.47
In a nonrandomized, longitudinal, prospective study, 24
Vitamin D supplementation
women with PCOS each received 10–14 sessions of EA. EA
Approximately 67–85% of women with PCOS are deficient was administered twice a week for 2 weeks and once a week
in vitamin D.42 In women with PCOS, low vitamin D thereafter. Acupuncture points were selected in the ‘somatic
levels are associated with obesity and metabolic and endo- segments common to the innervation of the Ovary and
crine disturbances.43 Therefore, it may be prudent to screen Uterus (Th12–L2, S2–S4)’. One-third of women re-
all women with PCO/PCOS for vitamin D deficiency. established regular ovulatory cycles following EA treat-
Vitamin D supplementation should be offered to those ment. EA was more effective in women with lower BMIs,
patients found to be deficient on the assumption that waist-to-hip circumference ratios, and serum testosterone
it may improve menstrual frequency and metabolic concentrations.48
disturbances.43
Acupuncture treatment
Acupuncture treatment of PCOS The greater the severity of menstrual irregularities, the
greater the severity of PCOS.26 Therefore, one of the aims
Research on acupuncture and PCOS of acupuncture treatment is to improve menstrual cycle
Conventional medical treatment of PCOS has inconsistent regularity.
results, is expensive, and is associated with an increased risk One way to do this is to help overweight patients lose
of multiple gestation pregnancy; there are also other associ- weight, which, in turn, will improve their hormonal bal-
ated adverse effects.44 Acupuncture is a safe, viable alterna- ance and menstrual cycle regularity. The TCM pathology
tive.44 In their review paper, Lim and Wong state that associated with obesity includes Kidney Yang Deficiency
acupuncture may help to increase blood flow to the ovaries, and Damp-Phlegm. Acupuncture points particularly useful
reduce ovarian volume and the number of ovarian cysts, and for obesity associated with PCOS include ST40, ST36, SP9,
control hyperglycaemia by increasing insulin sensitivity and LIV3, ST25, GB26, ST29, KID14, and KID3 (moxa and EA
decreasing blood glucose and insulin levels. Acupuncture’s can be useful adjuncts).
mode of action is by modulation of endogenous regulatory The Section ‘The importance of menstrual cycle
systems, including the sympathetic nervous system and the regulation’ provides detailed treatment algorithms for var-
endocrine and the neuroendocrine systems.45 ious menstrual cycle irregularities.
One small study of 66 women diagnosed with PCOS PCOS can have a significant effect on patients’ mental–
who were undergoing IVF showed that, in the group emotional health. Acupuncture can be used to address this
(n ¼ 32 cases) undergoing electroacupuncture (EA), there because pathology associated with PCOS (Damp-Phlegm,
was a significantly higher fertilization rate, cleavage rate, Stagnation, Yang, Yin imbalances and Blood Deficiency)
and high-quality embryo rate compared to an observation is also associated with emotional and psychological ill
group (n ¼ 34). The clinical pregnancy rate was also higher health.
in the EA group, but this did not reach statistical signifi- Common syndromes associated with PCOS include Kid-
cance. EA was administered once daily on acupuncture ney Yang Deficiency, Damp-Phlegm, Blood Stasis, Kidney
points REN4, REN3, SP6, ZIGONG, and KID3 during Yin Deficiency, and Blood Deficiency. Treating these syn-
one menstrual cycle before and during the IVF ovarian dromes may help to reduce the severity of the patient’s
stimulation phase.46 PCOS symptoms and, therefore, potentially increase the
In another trial, 62 women diagnosed with PCOS who patient’s chances of spontaneous conception.
were undergoing an IVF/Intracytoplasmic Sperm Injection In the authors’ opinion, acupuncture treatment should
(ICSI) cycle of treatment were randomized into the EA be attempted for 4–8 menstrual cycles, depending on the
group (n ¼ 31) and a control group (n ¼ 31). The EA group patient’s age and the length of menstrual cycles. If regular
received five sessions of EA (at the start of downregulation, ovulatory cycles are not re-established or if no conception
start of stimulation, 2 days before egg retrieval, and imme- occurs, these patients should be referred for Orthodox ovu-
diately before and after embryo transfer). In the first three lation induction therapy such as CC.
sessions, the following acupuncture points were used: LI4, Table 8.3 lists TCM syndromes common in patients with
SP6, LIV3, REN4, DU20, ST36, and the Ovary and Uterus PCOS and their treatment with acupuncture; Figure 8.3
auricular points, bilaterally. In the pre- and post-embryo provides a PCOS patient management algorithm.
193
Table 8.3 Common TCM syndromes in patients with PCOS and their treatment with acupuncture
Kidney Yang Deficiency Phlegm-Damp with Blood Stasis Kidney Yin Deficiency,
with Damp-Phlegm Liver Blood Deficiency,
Stagnation/Blood
Stasis
Manifestations No or scant periods49 The same as Kidney Yang Deficiency with Irregular or infrequent
Anovulation50 Damp-Phlegm ovulation50
Infrequent menstruation50 plus Infrequent menstruation50
Obesity49–51 Abdominal pain49 Thin body shape50
Excessive vaginal discharge49 Restlessness50
Feeling of heaviness in the Stress, depression,
abdomen49 or generally51 tearfulness51
Cold limbs, aversion to cold51
Dispirited, depressed
Pulse Weak, slippery49 Weak, slippery,49 wiry Wiry, fine,51 may be rapid
51
Tongue Pale, swollen, sticky white Pale-purple or pale-blue, swollen, sticky Red51
coating49 white coating49
Treatment Resolve Damp-Phlegm Resolve Phlegm and Damp Nourish Kidney Yin
principles Warm and tonify Kidney Tonify and warm Kidney Yang Regulate and tonify Qi and
Yang and Qi (with moxa) Eliminate Stasis Blood
Regulate Qi and Blood (with moxa)
Acupuncture SP6: Invigorates Blood, harmonizes the Lower Jiao, regulates the menstrual cycle, calms Shen (Spirit), promotes
points and fertility, and resolves Damp52
rationale KID3: Benefits the Kidneys, regulates the Chong (Penetrating) and Ren (Conception) Mai and the menstrual
cycle, and promotes fertility53
LIV3: Spreads Liver Qi, regulates menstruation and the Lower Jiao52
LU7 + KID6: Opens and regulates the Ren Mai (Conception Vessel),54 reinforces the Kidney, and tonifies the
ovaries55
SP4 + P6: Opens the Chong Mai (Penetrating Vessel),52 regulates Blood in the Uterus, nourishes Blood, benefits
Jing (Essence), regulates Qi, and eliminates Blood Stasis56
ZIGONG ‘Palace of the Child (Uterus)’: tonifies deficiency57
ST36: Tonifies and promotes Qi, resolves Dampness, and supports the Spleen and Kidney58
ST40: Transforms Phlegm-Damp, supports the Shen (Spirit), benefits the REN4: Nourishes Kidney
Spleen,58 and may help with weight loss Yin61
ST29: Regulates the menstrual cycle, warms the Lower Jiao (with moxa), and REN7: Benefits the Ren and
promotes fertility58 Chong Mai (Conception and
ST28: Benefits the Uterus, regulates the Lower Jiao, dispels Stagnation (caused Penetrating Vessels)61
by Phlegm-Damp/Cold in the Uterus), and promotes fertility58 LIV8: Invigorates and
SP9: Regulates the Spleen, resolves Dampness, and benefits the Lower Jiao52 nourishes Blood and Yin,
GB26: Regulates the Dai (Girdle), the Chong (Penetrating), and Ren benefits the Uterus62
(Conception) Mai (Vessels); drains Dampness; regulates the menstrual cycle;
and promotes fertility59
TITUO: Raises Qi and supports Qi in the Lower Jiao (heaviness due to
Damp-Phlegm)57
P5: Transforms Phlegm, regulates the menstrual cycle, and benefits the Heart
and Uterus axis60
KID14: Regulates Qi, eliminates Blood
Stasis, regulates the menstrual cycle, and
promotes fertility53
ST30: Regulates the Chong Mai
(Penetrating Vessel), regulates the Lower
Jiao and the menstrual cycle, and promotes
fertility58
Electroacupuncture (EA) is a useful auxiliary treatment method for PCOS.46,48,63–65
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Identification and management of conditions detrimental to IVF Chapter |8|
Preparation phase
If PCOS is suspected, but not Review lifestyle factors and make • Treat according to TCM
diagnosed, refer for investigations: recommendations: syndromes
• free testosterone or free • weight loss if excess weight • Regulate the menstrual cycle
androgen index to assess • weight gain if underweight • Provide mental-emotional
hyperandrogenism • exercise support
• progesterone test to assess • vitamin D supplements if • Allow a minimum of 4 months
ovulation deficient treatment
• ultrasound assessment of • Electroacupuncture is indicated
ovaries
Figure 8.3 Algorithm of acupuncture management of patients with PCOS who are undergoing ART.
INTERESTING FACTS
HIRSUTISM AND PCOS
CLASSICAL TCM AND CONTEMPORARY ORTHODOX MEDICAL PHYSIOLOGY
® The Chong and Ren Mai (Penetrating and Conception abundance of Blood in the Chong and Ren Mai, which
Vessels) influence the abdomen, chest, face, and the area nourishes the abdomen, chest, and face, resulting in body
around the mouth.66 In women with PCOS, these areas hair growth.66
commonly show excessive hair growth; this is referred to ® In women diagnosed with PCOS, pathogenic factors
as male pattern hair growth or hirsutism. This suggests such as Phlegm-Damp, Qi Stagnation, and/or Blood
that, in TCM, PCOS is linked to Chong and Ren Mai Stasis may obstruct the Chong and Ren Mai, resulting in
pathology. no or infrequent periods. This obstruction creates an
® In TCM, men have facial and body hair because they do overabundance of Blood similar to that in men66 and
not have regular menstrual cycles. Thus, males have an leads to male pattern hair growth or hirsutism.
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Acupuncture for IVF and Assisted Reproduction
Case study
Overview
Thyroid disease is characterized by either the under- or Aetiology
overproduction of thyroid hormone. The thyroid gland, The causes of hypothyroidism include:67
which is located in the neck, produces two thyroid hor-
mones: triiodothyronine (T3) and thyroxin (T4). Their pro-
• Hashimoto’s thyroiditis (an autoimmune disorder)
duction is regulated by Thyroid Stimulating Hormone
• Diet low in iodine
(TSH), which is produced by the pituitary gland. Thyroid
• Thyroid surgery or radioactive iodine therapy
hormones regulate the body’s metabolism and, hence, its
• Unidentifiable causes
ability to convert food into energy.67 Causes of hyperthyroidism are:68
Hypothyroidism is the underproduction of thyroid hor- • Smoking
mones by the thyroid gland.67 Hyperthyroidism is the • High iodine intake (Grave’s disease)
result of an overactive thyroid gland that produces excessive • Low iodine intake (nodular goiter)
thyroid hormones.68 • Female gender (affects 20 times as many women as men)
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Identification and management of conditions detrimental to IVF Chapter |8|
Orthodox medical management thyroxine (FT4), and free triiodothyronine (FT3) levels.
of thyroid disease Other thyroid disease markers such as thyroid antibodies
may also be tested to identify the cause of thyroid dysfunc-
Indications for biochemical tests tion, for example, an autoimmune disease.70 Thyroid tests’
reference ranges are provided in Table 8.4.
Routine thyroid screening is expensive70 and is not recom-
mended for subfertile patients.71 However, thyroid investi-
gations are indicated in patients with ovulatory disease or
in patients with risk factors for thyroid disease.71 The risk Management of patients
factors for thyroid disease are outlined in Box 8.1. with hypothyroidism
The first step in the development of hypothyroid disease is
Thyroid function tests
when the pituitary gland produces increasing levels of TSH,
If thyroid disease is suspected, then Thyroid Function Tests but the FT4 and FT3 levels remain within the normal range.
(TFT) should be performed. This includes testing TSH, free
Box 8.1 Risk factors necessitating thyroid testing Table 8.4 Thyroid tests’ reference ranges
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Identification and management of conditions detrimental to IVF Chapter |8|
ovulation irregularities may reduce the chances of with subclinical or overt thyroid disease should be moni-
conception. tored very closely during their pregnancy. Their medication
Hyperthyroidism is associated with hypomenorrhoea levels may need to be adjusted every 4–6 weeks.89
(scant) and/or polymenorrhoea (very frequent (<21 days) In 2012, the American Thyroid Association published
menstruation).83 guidelines on the diagnosis and management of thyroid
disease during pregnancy and postpartum. These guide-
Effect on ART lines were approved by the ATA Board of Directors and offi-
cially endorsed by the American Association of Clinical
High oestrogen levels during controlled ovarian stimulation
Endocrinologists (AACE), the British Thyroid Association
can have an adverse effect on pre-existing thyroid disease.83
(BTA), the Endocrine Society of Australia (ESA), the
A lower fertilization rate is often reported in women with
European Association of Nuclear Medicine (EANM), the
hypothyroidism compared with euthyroid women.84,85
European Thyroid Association (ETA), the Italian Associa-
Raised thyroid antibody levels may adversely affect the
tion of Clinical Endocrinologists (AME), the Korean Thy-
rates of clinical pregnancy.86 A meta-analysis found that
roid Association (KTA), and the Latin American Thyroid
treatment with thyroxin improves the clinical pregnancy
Society (LATS).73
outcomes in women with subclinical hypothyroidism or
There is disagreement in the published literature about
autoimmune thyroid disease undergoing ART treatment.87
whether subclinical or overt hypothyroidism affects preg-
nancy outcomes. In its latest clinical practice guidelines,
CLINICAL TIPS the American Thyroid Association states that high-quality
evidence supports the view that both subclinical and overt
HYPOTHYROIDISM MEDICATION AND IVF hypothyroidism increase the risk of adverse pregnancy
High oestrogen levels during controlled ovarian stimulation outcomes.73
have been shown to negatively affect thyroid hormones, Raised thyroid antibodies have been linked to pregnancy
causing TSH to rise above pregnancy-specific reference loss.73 A large meta-analysis found that pregnant women
range levels even before conception occurs.88 with subclinical hypothyroidism or thyroid antibodies have
Therefore, patients taking thyroxine medication while an increased risk of complications, especially preeclampsia,
undergoing controlled ovarian stimulation may need to perinatal mortality, and (recurrent) miscarriage.90
discuss with their endocrinologist possibly increasing their Whilst treating overt and subclinical thyroid disease in
thyroxine medication while undergoing IVF. women who are trying to conceive or are pregnant70,73 is
recommended, there is not enough good-quality evidence
to determine if treating euthyroid women with raised thy-
Effect on pregnancy and the foetus roid antibodies improves pregnancy outcomes and what
During the first 10–12 weeks’ gestation, the baby is treatment is the most effective.91 Therefore, treatment of
completely dependent on the mother’s ability to produce euthyroid women with raised thyroid antibodies is only
adequate thyroid hormones. After this time, the baby is able recommended in the research setting.91
to produce its own thyroid hormones but is still dependent All thyroid medication crosses the placenta.83 Therefore,
on its mother taking an adequate amount of iodine. any possible beneficial effects of treatment with thyroxine
Untreated hypothyroidism can have a detrimental effect medication should be balanced with the risk of adverse
on pregnancy and can:67 effects on the foetus.
• Affect the development of an embryo.
• Lead to major and profound complications during
pregnancy and postpartum, such as miscarriages, CLINICAL TIPS
premature birth, and low birth weight. THYROID MEDICATION DOSE AND PREGNANCY
• Affect the development of the baby’s mental capacity.
Once pregnant, a woman’s physiological demand for thyroid
Untreated hyperthyroidism is associated with:89 hormones rises immediately. It is therefore recommended
• Miscarriages that women on levothyroxine medication should
• Pregnancy-induced hypertension independently increase their baseline dose of medication by
• Prematurity 30% (or in some cases even more) immediately on
• Low birth weight biochemical confirmation of pregnancy.73,89
• Intrauterine growth restriction
• Stillbirth
• Thyrotoxic crisis (thyroid storm) Effect on male fertility and reproductive
• Maternal congestive heart failure health
Because of the severe detrimental effects that thyroid dis- Thyroid disease may affect male reproductive functions.
ease can have on conception and pregnancy, all women However, this has not been extensively investigated. Most
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Acupuncture for IVF and Assisted Reproduction
of the human studies are small, and the effects observed are should be lowered to a more clinically relevant level of
not always statistically significant. After reviewing the avail- 3.0 mU/L,76 2.5 mU/L,72,77 or even 2.0 mU/L.78
able evidence, Krassas et al. concluded that thyroid disease As already mentioned, there is also lack of consensus in
can affect the male reproductive system in a number of the major thyroid medical associations’ guidelines about
ways:83 what should be done in cases where women with a history
• Thyroid disease can disrupt the reproductive hormonal of subfertility have TSH levels >2.0 mU/L but <4.5 mU/L.
balance. According to the American Thyroid Association’s 2012
• Thyroid disease can affect sexual function, producing Guidelines on the Diagnosis and Management of Thyroid
erectile abnormalities, low libido, and premature or Disease During Pregnancy and Postpartum, these women
delayed ejaculation. would benefit from low-dose thyroxine replacement,73
• Hyperthyroidism can affect sperm motility. whereas according to the British Thyroid Association’s Guide-
• Hypothyroidism can affect sperm morphology. lines for the Use of Thyroid Function Tests, these TSH levels
are of no concern unless they rise to >4.5 mU/L.70
This lack of clarity is, to an extent, reflected in the way
Lifestyle factors patients with thyroid test results in this range are medically
managed by their doctors. In our experience, there is a wide
Iodine is a significant component of the thyroid hor-
variation in how patients whose TSH is within this range
mones.92 Therefore, it is recommended that all women
are managed. Some patients are prescribed thyroxine med-
who are attempting to conceive or who are pregnant should
ication, whereas others are told that they require no
take 250 mg of iodine supplement.73,93,94 They should also
treatment.
eat foods rich in iodine, such as cow’s milk, yoghurt, eggs,
There is also much variation in how patients with raised
cheese, white fish, oily fish, shellfish, meat, and poultry.94
thyroid antibodies are managed. Some patients are pre-
scribed thyroxine, some patients are given immunosup-
The role of acupuncture pressant therapies, and some patients are not given any
medical treatment at all.
Referral for investigations For patients with these borderline thyroid hormone
When obtaining patients’ medical and infertility history, an levels who are not given any Orthodox medical treatment,
acupuncturist needs to be aware of possible clinical signs of acupuncture treatment may be the only way to help reduce
thyroid disease and refer patients for investigations, if the negative effects that their condition may potentially
appropriate. have on their reproductive health.
In those patients who are prescribed thyroid medication,
acupuncture may enhance its effectiveness and the patient’s
Treatment with acupuncture response. Table 8.5 provides an overview of common syn-
Management of patients with thyroid disease, particularly dromes and pathology associated with hypothyroidism
subfertile patients or patients suffering from miscarriage(s), and ART. Table 8.6 provides an overview of common syn-
is complicated by a lack of consensus on what is considered dromes and pathology associated with hyperthyroidism
a normal range of TSH. A new consensus is emerging that the and ART. Figure 8.4 summarizes how to manage patients
current normal reference range for TSH is set too high and with thyroid disease in preparation for ART.
Table 8.5 Overview of TCM syndromes and pathology associated with hypothyroidism
General manifestations Fatigue, tiredness, weight gain, constipation, irregular periods, low libido, erectile
abnormalities, premature or delayed ejaculation, hair loss, brittle hair and nails, dry itchy skin,
difficulty learning and remembering,73 anovulation or irregular ovulation, oligomenorrhoea
(infrequent or very light menstruation)67,83
Fertility and ART associations Low ovarian reserve75,82
Poor sperm morphology83
Lower fertilization rates84,85
Affect on embryo development:67 an increased embryo ‘drop out’ rate during embryonic
development in the laboratory
Failed IVF86
Miscarriage(s)67
Premature birth67
Low birth weight67
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Identification and management of conditions detrimental to IVF Chapter |8|
Table 8.5 Overview of TCM syndromes and pathology associated with hypothyroidism—cont’d
Blood test indication Raised TSH, low FT4 or
Raised TSH, normal FT4 (subclinical)
Outline of TCM pathology, Kidney Jing (Essence) Deficiency95
differentiation, and treatment Key symptoms: exhaustion,96,97 low levels of energy,98 depression,97 listlessness,99 hair
loss,99,100 forgetfulness,101 poor memory,99 irregular periods,102 weak sexual activity99
Pulse: leathery,103 weak, fine
Tongue: pale, may have white coating or be red
Acupuncture points: REN4, KID12, KID4 (moxa)
Qi Deficiency95,104
Key symptoms: tiredness,105–107 lassitude,106 breathlessness,108 sweating,105 poor
appetite,106 palpitations105
Pulse: empty106
Tongue: normal or pale106
Acupuncture points: LI18, REN17, REN4, REN12, ST36, LU9, HE5, LI10 (moxa)
Yang Deficiency95,104
Key symptoms: tiredness,104–106 lethargy,105 overweight, feeling of cold,99,105 bright white/
pale face,105 cold limbs,105 aversion to cold,95 low libido, impotence99
Pulse: deep-weak105
Tongue: pale, wet, swollen105
Acupuncture points: DU4, KID3, BL52, REN17, REN6, HE5, ST11 (moxa)
Blood/Yin Deficiency95,104
Key symptoms: poor memory,105 forgetfulness,109 brittle nails, dry hair/skin,110,111
impotence,112,113 premature ejaculation,100,114 constipation,99,107 dizziness,99,105,111 scant
menstruation,111 infrequent or irregular menstrual cycles,115,116 hair loss110
Pulse: fine, choppy105
Tongue: pale, thin, dry105
Acupuncture points: HE6, LIV3, REN4, REN12, SP6, ST39, ST9
Phlegm-Dampness
Key symptoms: somnolence,110 tiredness, muzzy head, dizziness,117 overweight110
Pulse: wiry, fine, slippery
Tongue: sticky coating or dry117
Acupuncture points: ST40, ST36, SP9, SP3, ST11 (moxa)
Hashimoto thyroiditis Damp-Phlegm, Spleen-Qi Xu, Kidney Yang118
Key symptoms: signs and symptoms of hypothyroidism, raised thyroid antibodies, recurrent
miscarriage, preeclampsia, perinatal mortality,90 drooping eyelids, swelling of the face104
Acupuncture points: REN4, REN22, REN23, LI18, HE7, ST40, SP3, KID3, ST36 (moxa)
Table 8.6 Overview of TCM syndromes and pathology associated with hyperthyroidism
General manifestations Irritability, heat intolerance, excessive sweating, palpitations, tachycardia, fine tremors, warm
and moist skin, weight loss with increased appetite, increased bowel movements,
oligomenorrhoea, eyelid retraction or lag68
Fertility and ART associations Poor sperm motility83
Miscarriage(s)89
Pregnancy-induced hypertension89
Premature birth89
Low birth weight89
Intrauterine growth restriction89
Stillbirth89
Maternal congestive heart failure89
Thyroid storm89
Continued
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Acupuncture for IVF and Assisted Reproduction
Table 8.6 Overview of TCM syndromes and pathology associated with hyperthyroidism—cont’d
Blood test indication Low TSH, raised FT4
Outline of TCM pathology, Yin Deficiency with Empty-Heat/Fire119,120
differentiation, and Key symptoms: scant menstrual flow, infrequent menstruation, ‘menstrual block’,116
treatment palpitations,115 tachycardia,115 nervousness, insomnia,120 fine tremors, feeling warm, night
sweats,109,115,116 weight loss,121 eye distension,119 eye lag
Pulse: rapid99,120
Tongue: red, peeled99
Acupuncture points: BL15, BL18, BL17, BL23, KID6, KID2, LIV8
Phlegm-Heat/Fire119,120
Key symptoms: eye retraction,120,122 eye lag, vexation, palpitations, sweating,122,123 nodular119
goitre120,123
Pulse: rapid, slippery, wiry
Tongue: sticky yellow coating122
Acupuncture points: P5, ST40, HE8, HE7, ST44, LI11
Fire119
Key symptoms: vexation, agitation, quick temper, heat intolerance,109,116,124,125 eye distension,
eyelid retraction, increased bowel frequency,119 sweating, increased appetite, weight loss,110
insomnia119
Pulse: rapid
Tongue: red
Acupuncture points: P8, HE9, LIV2, ST44, LI11, SI4
Case study
Subclinical Thyroid Disease and IVF even more elevated (4.7 mU/L), and her thyroid peroxidase
Sandra, who was 34 years old, presented for acupuncture antibodies were also elevated. Sandra was prescribed 75 mg of
treatment in preparation for and during her second round of thyroxine per day. When reviewed a month later, her TSH was
IVF. In her first cycle of IVF, she had two good-quality 1.4 mU/L, and she was given the go-ahead for her second
blastocysts transferred. Sandra began to bleed on the 11th day IVF cycle.
following egg retrieval, and her pregnancy test was negative. In the meantime, she was receiving weekly acupuncture
When reviewing her test results, I noticed that her TSH level treatment. Her main TCM syndromes were Spleen Yang
was 2.68 mU/L and FT4 was 11.9 pmol/L (the lower end of the Deficiency and Phlegm. Acupuncture points prescription
normal range). On further questioning, Sandra revealed that included SP3, SP6, SP9, ST36, ST40, and ST29.
her mother had thyroid disease. She also reported feeling tired; Sandra underwent her second cycle of IVF. She had two
needing to use a blanket in the evenings because she felt very top-grade blastocysts transferred, and two blastocysts were
cold; and having irregular menstrual cycles, low libido, and frozen. She conceived and successfully carried to full term.
hair loss. Sandra delivered a healthy baby girl naturally.
In view of Sandra’s history of infertility, her This case is a good example of how important it is
symptomatology, her slightly elevated TSH level, and her that acupuncturists check all test results and, if required,
family history of thyroid disease, I referred her to an refer patients for a second opinion. An integrated approach
endocrinologist with a special interest in infertility. Sandra to subfertility care almost certainly made a difference to the
underwent further thyroid investigations. Her TSH level was outcome of this patient’s second IVF treatment cycle.
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Identification and management of conditions detrimental to IVF Chapter |8|
TSH 0.4–2 mU/L TSH 0.4–2.0 mU/L TSH 2.0–4.5 mU/L TSH >4.5 mU/L
Antibodies normal Antibodies elevated or
TSH <0.4 mU/L
Figure 8.4 Acupuncture management of patients with thyroid disease in preparation for ART.
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Acupuncture for IVF and Assisted Reproduction
There are many hypotheses to explain endometriosis. lesions can be red, pigmented, or white. White lesions are
The most accepted explanation is that endometriosis is more difficult to examine visually.128 Therefore, if the diag-
caused by retrograde menstruation.127,128 This may be nosis is not apparent on visual inspection during surgery,
exacerbated by a compromised immune system that fails then histological evaluation is necessary.128,130 However,
to clear the lesions.127,129 Distal locations could result as with any surgery, the risks of surgery must be balanced
from lymphatic or haematogenous spread or metaplastic with any possible benefits to be gained by confirming or
transformation.127,129 excluding endometriosis. For example, if a woman who is
trying to conceive is suspected to have endometriosis and
her husband’s sperm parameters are poor, this couple
Risk factors should be referred for IVF because there is no benefit to be
Risk factors for endometriosis include: gained from confirmation of an endometriosis diagnosis.
Low BMI130–133 Serum levels of cancer antigen 125 can be raised in
•
Alcohol use130,131 patients with endometriosis, but because of poor sensitivity
•
Smoking130,131 and specificity, this should not be used as a diagnostic
•
Low vitamin D levels134 tool.128 Other biomarkers of endometriosis are currently
•
Diet low in dairy134 under investigation.143
•
Genetic predisposition135 Endometriosis can be staged according to the ASRM
•
African American ethnicity130,131 classification:142
•
• Early or late menarche136 • Stage I: minimal
• Stage II: mild
• Stage III: moderate
Signs and symptoms • Stage IV: severe
Patients may be completely asymptomatic or have a wide The classification depends on the location, severity, and
range of signs and symptoms.137 Medical history and clin- depth of endometrial implants, and the presence and sever-
ical signs suggestive of endometriosis include: ity of adhesions and/or endometriomas. Minimal or mild
• Dysmenorrhoea (severely painful menstruation)130,138 endometriosis is characterized by superficial lesions and
• Lower abdominal pain138 or bloating139 mild adhesions. Moderate to severe endometriosis is char-
• Lethargy139 acterized by the presence of endometriomas and more
• Cyclic or chronic pelvic pain130,138 severe adhesions.142
• Constipation or diarrhoea139 The Endometriosis Fertility Index (EFI) is a new validated
• Low back pain138,139 tool that has recently been developed to predict pregnancy
• Dyspareunia (painful intercourse)130,138 rates in patients with confirmed endometriosis who may
• Dyschezia (pain on defecation)138 want to attempt a natural conception; use of the EFI may
• Pain on micturition (urination)138 help to determine which patients may benefit from ART
• Pain on exercise138 treatment.144
• Loin pain138
• A fixed retroverted uterus130
• An adnexal mass130 Effect on fertility and reproductive
• Uterosacral ligament nodularity, thickening, or
health
tenderness (on vaginal or rectal examination by a
doctor)130 Approximately 25–50% of subfertile women have endome-
• Endometrioma(s) visualized on ultrasound triosis, and 30–50% of women with endometriosis are sub-
examination130 fertile.130,131 Though endometriosis is associated with
If the endometrial tissue affects the bladder, a patient may subfertility, the link has not been conclusively proven,
experience urinary symptoms such as frequent or painful and the causal relationship has not been clearly estab-
urination.140 If the bowel is affected, there may be alter- lished.130 However, it is well established that endometri-
ation of bowel habits.141 The symptoms that are experi- osis can cause physiological changes in the body that
enced are usually cyclical in their pattern. may compromise fertility.130
Pregnancy may reduce the severity of endometriosis, but The ASRM reviewed the evidence on the possible mech-
symptoms usually return some time after pregnancy.142 anisms of how endometriosis could affect fertility. Several
mechanisms have been proposed although it should be
noted that none of these mechanisms have been proven.
Diagnosis and staging These postulated mechanisms include:130
The only way to confirm the diagnosis of endometriosis is • Distorted pelvis anatomy: the presence of
by laparoscopy and histological evaluation.130 Endometrial endometriosis could lead to the formation of
204
Identification and management of conditions detrimental to IVF Chapter |8|
adhesions, fibrosis, and scarring that may distort the The choice of endometriosis treatment depends on the goal
pelvic cavity and lead to compromised functioning of of the treatment. In subfertile patients, the aim of the treat-
reproductive anatomy. The transportation function of ment is to reduce the negative effects that endometriosis
the fallopian tubes has also been shown to be could have on a woman’s fertility and ability to conceive
compromised in women with endometriosis although (for example, the aim would be to reduce endometrial tis-
more research is necessary to confirm this. sue implants and restore normal pelvis anatomy). There-
• Altered peritoneal function: women with endometriosis fore, the treatment options appropriate for women not
have been shown to have an increased volume of planning pregnancy might not be equally suitable for
peritoneal fluid and elevated inflammatory markers. women actively trying to conceive.
This may raise the possibility that endometriosis is
either caused by or results in systemic inflammation.
Expectant management
• Hormonal and menstrual cycle abnormalities: women
with endometriosis may have menstrual cycle Expectant management may be appropriate for patients
abnormalities such as an abnormally long follicular with mild to moderate disease. However, it may lead to a
phase (including low oestrogen levels) and luteal delay in other, more effective treatment methods, such as
phase dysfunction (including low progesterone levels). IVF.127 Expectant management should only be considered
They may also have abnormal follicular growth, for younger patients with good ovarian reserve.130 For
unruptured follicle syndrome, and premature and/or older patients (>35 years of age), more aggressive treat-
multiple LH surges. ments, such as IVF, should be considered.130
• Impaired embryo implantation: this may be caused by The newly developed EFI tool may help to identify those
the lack of certain molecules or enzymes in the patients who are least likely to benefit from expectant
endometrium of women with endometriosis, but more management.144
research is needed to investigate this further. Women
with endometriosis also have increased antibodies to
endometrial antigens, which can affect endometrial Medical treatment
receptivity and embryo implantation. As described earlier, endometriosis is an oestrogen-
• Compromised egg and embryo quality: embryos derived dependent disorder.127 Medical treatment aims to reduce
from women with endometriosis appear to develop more oestrogen production; this suppresses ovulation, thus rend-
slowly. Donor embryos obtained from women with ing women infertile while on such medication.130 A 2007
endometriosis have lower implantation rates, whereas Cochrane review found that ovulation-suppressing agents
donor embryos from women without endometriosis (danazol, progestins, oral contraceptives, and GnRH ago-
have normal implantation rates even if they are nists) produced no beneficial effect in infertile women
transferred into women with endometriosis. This suggests and delayed live births.146
that the faulty implantation is caused by embryo quality. However, pretreatment with GnRH agonists may improve
There is also growing evidence that endometriomas IVF outcomes. A 2006 Cochrane review found that long-
adversely affect ovarian reserve.145 term (3–6 months) GnRH agonist treatment in preparation
for IVF or ICSI increased the chances of pregnancy four-
fold.147 Pretreatment with oral contraceptives for 6–8 weeks
Orthodox medical treatment before ART also improves outcomes.148 Data is inconclusive
about whether pretreatment with a GnRH agonist improves
Endometriosis treatment options include: outcomes in patients with endometriomas.127
• Expectant management (close monitoring)127 In summary, prolonged therapy with a GnRH agonist
• Medical treatment127,128 or contraceptive agents should be considered before ART
n Nonsteroidal anti-inflammatory drugs but should not be administered to assist with natural
n Combination oral contraceptives conception.
n Progestins (oral, parenteral, implants, intrauterine
devices)
n GnRH agonists
Surgical treatment
n Danazol The benefits of surgery for endometriosis include restora-
n Aromatase inhibitors tion of pelvic anatomy and removal of endometriotic
• Surgical treatment127,128 implants and endometriomas, with a resulting decrease
n Laparoscopy with surgical excision of lesions in inflammation.127 It is well established that laparoscopic
n Laparotomy with surgical excision of lesions surgical removal of endometriosis is effective in improving
n Hysterectomy with ovarian conservation fertility in patients with stage I/II endometriosis.149 The
n Hysterectomy with removal of ovaries ASRM also recommends conservative surgery in subfertile
• ART treatment (to assist with conception)127 women with stage III/IV endometriosis.130 If conception
205
Acupuncture for IVF and Assisted Reproduction
does not occur after surgery, additional surgeries will not undergoing ART treatment. Patients with mild symptoms
offer any additional benefits, and these patients should may also benefit from an immediate referral if they are over
be referred for ART treatment.130 the age of 35 or have evidence of reduced ovarian reserve.
A 2008 Cochrane review found that surgical removal of Younger patients with good ovarian reserve may benefit
endometriomas is likely to increase chances of natural con- from a trial of acupuncture treatment to help them con-
ception.150 However, it is not clear if the surgical removal of ceive naturally.
endometriomas improves IVF outcomes.130,151 The ASRM All patients with severe endometriosis (stage III/IV) will
recommends that only the endometriomas that are >4 cm benefit from long-term pretreatment with a GnRH agonist,
in diameter should be surgically removed before IVF to and patients with endometriomas >4 cm may benefit from
improve access to follicles and possibly improve response surgery prior to IVF. The acupuncturists’ role is to refer the
to ovarian stimulation.130 Resection (rather than ablation affected patients.
or drainage) is the preferred surgical management of Figure 8.5 summarizes how to manage patients with
endometriomas.130 endometriosis in preparation for ART.
Removal of endometriomas may result in damage to
ovarian tissue and reduce ovarian reserve.152 Therefore,
any beneficial effects of such surgery need to be carefully
balanced against the risk of ovarian damage. A 2004 Treatment with acupuncture
Cochrane review found that suppression with a GnRH ago- In the authors’ opinion, acupuncture may improve ART
nist prior to surgery may decrease the size of endometriotic outcomes in patients with endometriosis by optimizing
implants and, therefore, reduce the size of the ovarian the quality of the eggs and the embryos, improving endo-
tissue that needs to be surgically removed.153 metrial receptivity, and reducing inflammation. Acupunc-
turists should aim to reduce the severity of the
underlying TCM pathology.
ART treatment In TCM, chronic pelvic pain is associated with Blood Sta-
There is a consensus that a stimulated Intrauterine Insem- sis, Damp-Heat, and Kidney Deficiency.124,156 Cold or
ination (IUI) is an effective treatment option in women Heat may also cause pain. Table 8.7 provides the differen-
with mild to moderate endometriosis.126,149 However, tial diagnosis and treatment with acupuncture. The
IVF is preferable in patients with severe endometriosis.149 section ‘The importance of menstrual cycle regulation’ pro-
Endometriosis may affect IVF outcomes. A 2013 meta- vides detailed algorithms that may be useful in endometri-
analysis of 27 studies and 8984 women undergoing IVF osis patients suffering with painful periods and/or other
concluded that the presence of severe endometriosis (stage menstrual abnormalities. Regulating the menstrual cycle
III/IV) is significantly associated with poor implantation can help to rectify Qi and Blood dysfunction, facilitate
and pregnancy rates. There was also a nonsignificant trend the flow of Qi and Blood in the Uterus, and promote
of reduced live birth rates. Mild endometriosis (stage I/II) fertility.
did not appear to have detrimental effects.154
As mentioned earlier, long-term pretreatment with a
GnRH agonist or oral contraceptives may improve IVF out- Red flag
comes.147,148 The ICSI fertilization method has been
shown to result in better fertilization rates, a higher mean Acute pelvic pain
number of embryos, and lower rates of total fertilization Patients with acute pelvic pain should be referred
failure or abnormal fertilization.155 immediately to their GP to exclude dangerous pathology –
for example, an infection, appendicitis, or ovarian torsion.
206
Identification and management of conditions detrimental to IVF Chapter |8|
207
Acupuncture for IVF and Assisted Reproduction
Endometriosis Endometriosis
Yes No
confirmed not confirmed
IUI or IVF
(see Chapter 9)
Figure 8.5 Acupuncture management of patients with endometriosis in preparation for ART.
208
Identification and management of conditions detrimental to IVF Chapter |8|
Table 8.7 Common TCM syndromes in patients with endometriosis and their treatment in preparation
for ART
Continued
209
Acupuncture for IVF and Assisted Reproduction
Table 8.7 Common TCM syndromes in patients with endometriosis and their treatment in preparation
for ART—cont’d
210
Identification and management of conditions detrimental to IVF Chapter |8|
Table 8.7 Common TCM syndromes in patients with endometriosis and their treatment in preparation
for ART—cont’d
Continued
211
Acupuncture for IVF and Assisted Reproduction
Table 8.7 Common TCM syndromes in patients with endometriosis and their treatment in preparation
for ART—cont’d
Notes: Consider TCM combined patterns and syndrome staging (i.e., early, mild, or advanced). Examine pathology and physiology and incorporate
into treatment principles.
• Uterine factor: a history of caesarean sections may • Intercourse practices: a couple may have less frequent
increase the risk of secondary infertility caused by uterine intercourse because of, for example, exhaustion from
scarring.183 Uterine infections following delivery may caring for a young baby or toddler.
cause scarring in the uterus and/or fallopian tubes. • Stress: a couple may find their inability to conceive
• Genetic issues: it is important to enquire if a previous another child a very stressful experience, especially if
pregnancy was achieved with the same partner or a their first baby was conceived very quickly.
different partner. If a different partner, it is important to • Occupational factors: have one or both of the partners
exclude genetic incompatibility issues by referring for changed their occupation(s), and, if so, is the new
karyotyping tests. occupation associated with subfertility?
• Immune issues: some women may develop immune • Breastfeeding: is the female partner still breastfeeding?
issues subsequent to a successful delivery.184 If so, this may suppress ovulation.
• Age: it might take longer to conceive another child
because of an age-related decline in fertility.
• Menstrual cycle irregularities: did the menstrual cycle Orthodox medical management
return to normal following the previous pregnancy? If
of secondary infertility
not, it may be prudent to refer the patient for hormonal
investigations, such as progesterone, thyroid, and The Orthodox medical management of secondary infer-
prolactin tests. tility is similar to that of primary infertility. Standard
• Weight: being over- or underweight can affect fertility. tests are normally undertaken. The management of the
Therefore, it is important to ask if one or both partners’ couple’s infertility depends on the findings and subsequent
weight has changed since the last pregnancy. diagnosis.
212
Identification and management of conditions detrimental to IVF Chapter |8|
Medical causes
Orthodox medical treatment
Various congenital or acquired factors can affect the male
reproductive tract at pre-testicular, post-testicular, or Treatment options depend on the cause of subfertility and
directly at the testicular level,188 leading to: may include:
• A decrease or complete cessation of sperm production • Hormonal treatment
• Sperm blocked from being released • Surgery
• Sperm not functioning properly • ART (IVF, ICSI, Intracytoplasmic Morphologically
The most common medical causes of poor semen parameters Selected Sperm Injection (IMSI), donor sperm IVF)
in men include cryptorchidism (13%),189 varicocele (10%),189
congenital abnormality of the vas deferens (4%),189 and
endocrine abnormality (2%).189 In 57% of men with severe Hypogonadotrophic hypogonadism
oligospermia or azoospermia, no causes are found.189
Other medical causes include congenital anatomical Hypogonadotrophic hypogonadism is characterized by
defects; genetic abnormalities; infections; cancer treat- hyposecretions of LH and FSH. This may be caused by
ments (including chemotherapy and radiation); scarring genetic factors or acquired factors. Congenital conditions
from sexually transmitted diseases, injury, or surgery; vasec- are associated with delayed puberty, sparse or nearly absent
tomy or failure of vasectomy reversal; retrograde ejacula- body hair, gynaecomastia, and low testicular volume.
tion; and impotence or erectile dysfunction.188 Acquired conditions may manifest with low ejaculation
Certain medications can affect sperm production, hor- volume, beard growth, impaired libido, and asthenia.
mone balance, semen parameters, or erectile issues. Appen- The diagnosis is confirmed by hormone tests. Acquired
dix VI provides details of the most common pharmaceutical hypogonadotrophic hypogonadism could be caused by
drugs that are known to affect male reproductive function. tumours and, therefore, requires more advanced
investigations.188
Depending on the cause, treatment with hormonal
Lifestyle factors medication is usually successful and is likely to result in
spontaneous conception. Depending on which gene is
Chapter 7 reviewed the effects of various lifestyle factors on involved in congenital hypogonadotrophic hypogo-
male reproductive function and fertility. These are: nadism, genetic counselling may be indicated. Treatment
• Heavy use of alcohol with testosterone may improve the man’s reproductive
• Use of recreational drugs function.188
213
Acupuncture for IVF and Assisted Reproduction
214
Identification and management of conditions detrimental to IVF Chapter |8|
215
Acupuncture for IVF and Assisted Reproduction
Table 8.8 TCM syndromes and pathogenic factors in Table 8.9 TCM syndromes and acupuncture treatment
male factor subfertility and their Orthodox medical of male factor subfertility in preparation for ART
associations
Syndromes Acupuncture points
Syndromes/ Orthodox medical
Generic treatment Benefit Jing (Essence) and promote
pathogenic factors associations
principle fertility
Kidney Jing (Essence) and/or Testicular failure, anatomic/ KID12, REN4, ST30, SP6, LIV3, ST36,
Qi Deficiency194,195,200,205– congenital factors,208 issues HE7, KID3, SP8, BL23 + BL52
208 Moxibustion is indicated (except in
with spermatogenesis, poor
morphology and Heat or Fire pathology)
motility,200 absence of
Kidney Jing Tonify Jing (Essence)
sperm in the ejaculate,
(Essence) REN4 (moxibustion is indicated),
low sperm count,
Deficiency LIV3, ST27, ST36, SP6, HE5, SP8,
impotence15
BL23 + BL52, KID3
Kidney Yang and/or Ming Poor motility,210 low sperm
Kidney Yang Tonify Yang
Men (Fire of Life) count, poor
Deficiency REN6, REN8, GB25, DU4, BL23 +
Deficiency194,201,205,207–209 morphology201,207
BL 52, LIV3, ST36
Kidney Yin Congenital factors, pituitary Moxibustion is indicated
Deficiency200,201,207 and factors, issues with
Kidney Yin Enrich Yin
Liver Yin Deficiency205,209 spermatogenesis, poor
Deficiency KID6, ST27, SP6, ST36, LIV3, KID3,
morphology,194,200,201,210
HE6, SP8
poor motility,201,207,209,210
low sperm count194,201 Qi and Blood Tonify and facilitate Qi and Blood
Deficiency flow
Qi199 and Blood Low count,201 other sperm
SP6, ST30, LIV1, ST36, LIV3, HE7,
Deficiency201 parameters may also be
KID3, REN17
affected
Moxibustion is indicated
Damp-Heat in Lower Sexually transmitted
Damp-Heat Drain Damp and resolve Heat
Jiao15,194,200,201,205,207,209 diseases,194 immunological
KID10, LIV8, SP6, DU3, BL23, SP9,
subfertility,15 infections,207
LIV5, GB34
inflammation, low sperm
count, high rate of dead Blood Stasis Eliminate Blood Stasis
sperm, incomplete BL17, BL18, BL15, BL23, LIV3, SP4 +
liquefaction of sperm,201 P6, SP10
varicocele,
cryptorchidism200 Cold Warm Cold
ST29, ST27, REN4, ST36, REN8, DU4,
Phlegm194,201 or Postinfection, low sperm LI4, KID2
Damp194,200,208 count, poor morphology Moxibustion is indicated
and motility, absence of
sperm in the ejaculate201 Phlegm-Damp Resolve Phlegm-Damp
ST40, ST36, REN9, LIV3, KID13, SP9,
Blood Stasis194,201 Varicocele, ST36, REN3, SP3, SP8
cryptorchidism,200 Moxibustion is indicated
postsurgery, low sperm
count,201,207 poor Qi Stagnation Regulate Qi and Blood
motility201 LIV3, P6, P5, HE7, ST36, LIV8,
REN17
Cold194,201,208 Any semen parameters may
be affected Heat/Fire Clear Heat/Fire
P7, LIV2, SP10, LI11, BL18, BL15,
Qi Stagnation,194 Any semen parameters may BL17, BL21, BL23
Fire,205,209 or be affected
Heat194,200,207
216
Identification and management of conditions detrimental to IVF Chapter |8|
the classical TCM literature, with men routinely treated for fragmentation tests. In some cases, acupuncture may not
male factor subfertility.195,199 achieve a significant change in semen parameters, but it
may still increase the chance of pregnancy by improving
Length of treatment the genetic quality of sperm and the resulting embryo.
Therefore, acupuncturists should use other methods of
Spermatogenesis takes about 3 months. Therefore, it is monitoring progress in response to acupuncture treat-
important to treat a male partner for at least 3 months ment, such as changes in the pulse and tongue and
before an improvement in semen parameters can be improvement of syndrome signs and symptoms.
expected. Men are usually presumed to be fertile if their semen
parameters are normal. However, according to the ASRM,
Lifestyle factors male factor infertility may be present even when the semen
It is important that male patients are given evidence-based analysis is normal.185 If their DNA fragmentation index
lifestyle advice and monitored to ensure that the advice is were tested, it could indicate in some instances potentially
being followed. The effectiveness of acupuncture treatment significant infertility. Therefore, there may be value in
otherwise could be reduced. assessing all male partners from a TCM perspective, and,
if TCM pathology is identified, acupuncture treatment
should be recommended. Furthermore, in the authors’
Other markers of male fertility opinion, all men should be given preconception
Semen parameters are not the only measure of male evidence-based lifestyle advice even if semen parameters
fertility because men with poor semen parameters can still are normal (with exceptions in cases where frozen embryos
achieve a pregnancy. Other aspects, such as the DNA and/or sperm or donor sperm is used). Figure 8.6 summa-
quality of the sperm, are also important but are not rizes how to manage patients with reversible causes of male
routinely measured because of the high costs of DNA factor subfertility.
Case study
Male Factor Subfertility: Simple to Treat, More Review Post Second IVF Cycle
Difficult to Manage We discussed the importance of preparatory acupuncture in
Frances and Martin began trying for a baby when they order to allow sufficient time for any underlying pathology to
were both 21 years old. After 5 years of trying be addressed and lifestyle modifications to be made. I also
unsuccessfully, they were referred for further investigations. recommended that Martin have acupuncture in preparation
Frances had irregular menstrual cycles; Martin’s sperm count for their next IVF cycle.
was low (6 million sperm) with very poor motility and
morphology. They were advised that they had a 5% chance Third IVF Cycle
of conceiving naturally, but IVF/ICSI would be a good This time both Frances and Martin began acupuncture
alternative option. treatment 3 months in advance. Martin was diagnosed with Qi
and Blood Deficiency and received 10 acupuncture sessions.
First IVF Cycle Points used were HE7, ST36, KID3, DU20, and LIV3.
This time, 15 eggs were retrieved, 12 were mature, but only
Frances began acupuncture treatment 3 months before their three were fertilized by ICSI (despite Martin’s sperm count on the
first ICSI cycle. Martin did not, partly for financial reasons, day of fertilization being the best yet, at 19 million). Two medium-
partly because he was not keen on the needles, and partly
grade embryos were transferred on day 2. The treatment was
because he hoped that the ICSI technique would overcome successful, and, in a scan at 6 weeks, a healthy foetal heartbeat
his subfertility. During that cycle, 14 eggs were retrieved, of was observed (although Frances developed late onset OHSS,
which 12 were mature with seven fertilized by ICSI. Only one which was successfully managed with acupuncture.)
medium-quality blastocyst survived and was transferred. This
resulted in the birth of their son. Discussion
This case emphasizes several points:
Second IVF Cycle ® In couples with both male and female factor subfertility,
They decided to try for a sibling 2 years later. Again, Frances women are more likely than their partners to present for
had acupuncture, but this time she began the treatment when acupuncture.
she was already on downregulation medication. She had over ® Having acupuncture during the preparatory phase is very
20 follicles, but only four eggs were retrieved. One egg was important.
mature and fertilized by ICSI. A poor-grade embryo was ® ICSI is a powerful fertilization technique in male factor
transferred on day 3. Francis conceived but suffered a subfertility cases. However, in some cases, it can still result
preclinical miscarriage. in a poor fertilization rate.
217
Acupuncture for IVF and Assisted Reproduction
Consider if a referral should be Review lifestyle factors and • Treat according to TCM
made for advanced investigations make recommendations: syndromes.
such as hormonal tests, • Heavy use of alcohol • Allow a minimum of 3 months'
ultrasound, DNA fragmentation • Use of recreational drugs treatment.
analysis (see Chapter 4). • Being overweight
• Smoking
• Exposure to various
environmental toxins and heat
• Occupational factors
• Nutritionally poor diet
• Lack of exercise
• Psycho-emotional stress
• Older paternal age
• Infrequent ejaculation
Figure 8.6 Algorithm of acupuncture management of reversible causes of male factor subfertility.
218
Identification and management of conditions detrimental to IVF Chapter |8|
menstrual cycle abnormalities. This includes the assess- Ren (Conception) Mai (Vessels) to coordinate Qi and
ment of:216 Blood and menses.
• Activity: arriving early, late, or irregularly (sometimes
early, sometimes late), stop-starting flow or Regularity of the menstrual cycle
prolonged flow
• Amount: scant amount or heavy In TCM, a healthy menstrual cycle is considered to be 28–
• Colour: pale, purple, or bright red 30 days.97,218,219 In TCM, the menstrual cycle can be cate-
• Consistency: clotted, thin, or thick gorized according to its regularity:
The assessment of menses can also provide further diag- • An irregular cycle: more than 7 days variability.167
nostic details regarding the health of the Zangfu organs, • Early cycle: up to 7,167 8,156 9,220 or, in extreme cases,
Extraordinary Vessels, and the Uterus. Assessment of the 10 days early.167
menstrual cycle can also help identify the presence of • Late cycle: 7,167 8,162 or 9221 days late.
Heat/Fire, Stagnation, Blood Stasis, Phlegm-Damp, and/ • Extremely late cycle: 50 days221 to 3–5 months.167
or Cold. Some authors state that irregularities must occur for 2–
The next sections provide information about what is con- 3 months before a diagnosis can be made.167,220
sidered a regular menstrual cycle and common pathologies Figure 8.7 outlines principles for regulating the
during each phase of the menstrual cycle. We would cau- menstrual cycle.
tion against interpreting this information too rigidly. For
example:
Follicular phase (menses day 1–5)
• A cycle of 25 days may be normal in some women. But,
in a subfertile woman, particularly if she is of advanced Ideally, menses should last for about 5 days, the blood loss
reproductive age, it can signify Blood, Qi, and Kidney should not be too scant or too heavy, there should be no
Jing (Essence) Deficiency. Cycle length changes with pain or clots, and blood should be red.
age, gradually reducing to 27 days in women aged Common symptomatology experienced by women dur-
44 or older.217 ing menses is pain. The TCM differential diagnosis of pain
includes:
• It is not generally considered abnormal if a cycle is
delayed by a few days. However, this may be caused by the • Liver Qi Stagnation and Blood Stasis
effect of stress on Qi and Blood and can represent subtle n Distension
pathology. The overall picture should be considered n Severe stabbing pain
when deciding what is normal and what is not. n Worse with pressure
219
Acupuncture for IVF and Assisted Reproduction
Nourish Kidney Jing (Essence): Tonify Kidney Jing (Essence): Tonify Kidney Jing (Essence)
REN4, KID3, REN6, SP1 (moxa) REN4, SP6, KID5, LIV1, KID1, and nourish Blood:
KID15, ZIGONG ST29, REN4, P5, KID4, KID5,
ST36, SP6
Qi Deficiency
Spleen Qi Deficiency
Tonify Qi:
Blood Deficiency
SP1, REN4, HE5 (moxa) Tonify Qi:
KID3, ST36, SP4, HE5 Nourish Blood:
220
Identification and management of conditions detrimental to IVF Chapter |8|
Invigorate and regulate Qi and Blood flow, tonify Kidney Jing (Essence):
SP4 + P6, LU7 + KID6, REN4
Thin: Qi Deficiency Heat Blood Stasis Cold-Stasis Heat/Fire, Blood Yang Deficiency
Watery: Blood or Stasis
Clear Heat: Eliminate Stasis: Invigorate, warm Tonify Yang:
Yin Deficiency
LIV2, ST29, LIV5 ST29, LIV3, P6, Blood: Clear Heat/Fire: KID7, KID3, REN6,
Reinforce Kidney: KID14, SP10, ST29, ST28, ST29, LIV2, SP10, REN2 (moxa)
KID3, REN4, KID19, LI4 REN3, ST36 SP6, LIV4, P7
KID1, ST36 (moxa)
Nourish Blood: Tonify Kidney, Warm Blood: Invigorate Blood: Resolve Phlegm-
nourish Blood: Damp:
LIV8, KID3, HE7, ST28, REN4, REN8, KID14, LIV14, SP10,
ST36 REN4, KID13, KID12, BL17-BL23 (moxa) ST30 ST40, GB26, ST36,
KID5, ST36 (moxa) ST29 (moxa)
Heavy
Qi and/or Blood
Deficiency Blood Stasis Blood-Heat Empty-Heat
Tonify Qi and Blood, Eliminate Stasis, Cool Blood, stop bleeding: Clear Empty-Heat:
modulate bleeding: regulate Blood:
LIV1, LIV2, P7, HE5, KID27 KID2, SP10, KID8, SP6,
SP1, LIV8, P5, ST36, LIV1, ST29, LIV3, LIV6 HE6
REN12 (moxa)
Menstrual pain:
Liver Qi Stagnation Cold-Damp, Yang Kidney and Liver Damp-Heat Heat Kidney Yang
and Blood Stasis Deficiency Yin Deficiency Deficiency and
Clear Heat, resolve Clear Heat:
Blood
Regulate Qi and Warm Cold, Nourish Kidney Damp: LIV2, LIV1, SP10,
Blood, eliminate resolve Damp: Yin and Liver GB26, GB34, SP6, HE8 Tonify Kidney
Stasis: ST29, ST28 Blood: ST36, REN3, LIV5, Yang:
ST29, ZIGONG, LIV3, LIV8, SP10 Baliao, BL31–34,
KID14, LIV14, REN4, REN7, REN2, SP8 (moxa)
ST26 KID13, KID5
Figure 8.8 Menstrual cycle irregularities (menses: days 1–5)98,122,124,162,166,167,175,216,222,224,225 and acupuncture treatment.
221
Acupuncture for IVF and Assisted Reproduction
Kidney Jing
Kidney and Liver Kidney Yang Qi and Blood
(Essence) Cold
Deficiency Deficiency Deficiency
Deficiency
Tonify Kidney Jing Nourish Kidney Yin Tonify Kidney Yang: Tonify Qi, nourish Warm the Uterus,
(Essence): and Liver Blood: KID8, SP8 (moxa) Blood: regulate Qi and
ST27, REN4, ST29, KID3, ST30, SP8, KID8, SP8, LIV5, Blood:
LIV3 REN7, KID27 LlV3 ST28, ST29, REN4
(moxa)
Figure 8.9 Menstrual cycle irregularities (follicular phase: days 5–14)56,98,122,166–168,216,222,225 and acupuncture treatment.
222
Identification and management of conditions detrimental to IVF Chapter |8|
If spotting at mid-cycle:
Liver/Kidney Yin
Spleen/Kidney
Deficiency + Damp-Heat Blood Stasis
Yang Deficiency
Empty-Heat
Clear Heat, nourish Yin: Resolve Damp, clear Tonify and warm Yang: Eliminate Stasis:
KID2, KID6, KID3, LIV3, Heat: SP1, KID3, REN6, SP10, SP1, LIV1
HE6 LIV5, GB26, REN3, ST36, DU20 (moxa)
GB34
If ovulation pain:
Figure 8.10 Menstrual cycle irregularities (ovulation: days 14–16)56,98,167,168,222,227 and acupuncture treatment.
• Qi Deficiency
n Profuse or dribbling flow TREATMENT PLANNING: SETTING
n Pale red, thin consistency REALISTIC GOALS
• Liver and Kidney Yin Deficiency
n Sudden onset
n Bright-red flow
When treating ART patients, the majority of the patients
will need to be supported through four stages:
• Blood Stasis
n Scant or heavy flow (or mixed) • The initial case intake or case review
n Or dribbling flow (or mixed) • The preparation stage
n Dark red flow, thick and/or clotted consistency • ART treatment stage
• Qi ‘Depression’ Stagnation • Pregnancy support (if the treatment is successful)
n Sudden profuse bleeding Figure 8.12 provides a treatment planning algorithm that
n Purplish, clotted menses integrates conventional Orthodox medical management
Figure 8.11 outlines common syndromes that manifest diagnosis, the patients’ adoption and compliance with life-
during the luteal phase and the TCM acupuncture treat- style factors, and their ART history along with their TCM
ments for them. acupuncture management.
223
Acupuncture for IVF and Assisted Reproduction
If premenstrual tension:
Liver/Kidney Yin
Liver Qi Stagnation Phlegm-Heat/Fire Blood Heat
Deficiency
Regulate emotions, Clear Heat/Fire, resolve Nourish Yin and Blood: Cool Blood, calm Mind,
sooth the Liver, regulate Phlegm: DU20, LIV8, KID12, Shen (Spirit):
Qi: ST29, SP10, SP6, P5 REN7 HE3, LIV2, DU24
LIV2, LIV3, P6
If premenstrual bleeding/spotting:
Blood-Heat, Qi
Yin Deficiency Liver/Kidney Qi 'Depression'
Stagnation, Qi Deficiency
Empty-Heat/Fire Yin Deficiency Stagnation
Heat/Fire
Cool Blood, stop Nourish Yin, clear Tonify Qi, stop Enrich Yin, stop Regulate emotion,
bleeding: Heat, stop bleeding: bleeding: bleeding: modulate bleeding:
LIV2, SP1, P6, KID2, KID6, HE6 REN4, REN6, ST36, BL23, BL52, BL18, LIV2, LIV1, P7
SP10, LI11 DU20, SP1 LIV8, KID3
Figure 8.11 Menstrual cycle irregularities (luteal phase: days 16–28)98,116,122,125,161,165,167,216,230,231 and acupuncture treatment.
224
Medical history Lifestyle factors ART history TCM history
Case intake/
Review medical tests Identify modifiable Review previous ART Carry out TCM
review
and diagnosis. Refer lifestyle factors and treatment cycles (if any). diagnosis. Identify
for other tests and make recommendations Identify areas for which syndromes may
investigations, if (see Chapter 7). improvement and make interfere with ART
necessary (see RIF recommendations outcome and take
Chapters 4 and 8). (see Chapters 6, 10, corrective steps (see
and 12). Chapters 2, 5, and 8).
Ensure that patients Ensure that lifestyle Ensure that any RIF Treat identified
receive correct advice is being followed. preventive measures syndromes in female
treatment in preparation are actioned. and/or male partner(s).
for ART treatment (e.g., Regulate the menstrual
thyroid, PCOS, cycle in a female
endometriosis). partner (see Chapters
5 and 8).
If not
pregnant
Anticipate possible Ensure that lifestyle Ensure that any RIF Treat according to ART
complications and if advice is being followed. preventive measures treatment stage
Art
If
pregnant
Ensure that the medical Review lifestyle factors Review TCM diagnosis.
support
Figure 8.12 Orthodox and TCM integrated ART treatment planning algorithm. ART, Assisted Reproductive Technology;
RIF, Repeated Implantation Failure; TCM, Traditional Chinese Medicine.
225
Acupuncture for IVF and Assisted Reproduction
TCM history review process, then the patient should be assisted in taking
steps to prevent similar issues or complications arising in
A full TCM diagnostic triage should be undertaken, ideally
the next treatment cycle. For example, if the patient’s
in both male and female partners.
response to ovarian stimulation was poor, she may need
to speak to her consultant about changing her IVF treat-
Preparation stage ment protocol or increasing the dose of medication.
226
Identification and management of conditions detrimental to IVF Chapter |8|
227
Acupuncture for IVF and Assisted Reproduction
Menstrual cycle as far back as the Eastern Han Dynasty. Therefore, when
treating a female patient in preparation for ART, the men-
Research shows that menstrual cycle characteristics such strual cycle should be assessed and if necessary treatment
as cycle length, regularity, number of days of menstrual and management should be individualized based on
bleed can have an adverse effect on conception, miscar- identified syndromes and include acupuncture points
riage rates and IVF outcome. The importance of men- that will help to regulate the cycle.
strual cycle regulation was discussed in Classical TCM
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Chapter |9|
Acupuncture during ART
Chapter 6 introduced different types of Assisted Repro- the release of Follicle Stimulating Hormone (FSH) and Lutei-
ductive Technology (ART) treatments and techniques and nizing Hormone (LH) by the pituitary gland. As a result, fol-
explained how pharmacological drugs are used in manipu- licular growth is inhibited, preventing premature LH surge
lating reproductive hormones. This chapter builds on that and spontaneous ovulation and allowing for the availability
knowledge. It provides detailed information about each of more homogenous-sized follicles for recruitment.2
type of ART treatment and recommends an acupuncture
treatment protocol that can be used alongside ART. GnRH agonist
The GnRH agonist mode of action is to stimulate the pitu-
itary gland to produce more LH and FSH, which causes an
TREATMENT DURING IVF increase in oestrogen levels (flare-up). After approximately
10 days, pituitary suppression is achieved by exhaustion
In Vitro Fertilization (IVF) is an ART procedure that involves of the gonadotrophic pituitary cells resulting in the decline
fertilization of an egg by sperm in a laboratory dish.1 It is of FSH, LH, and oestrogen comparable to menopause.2
usually divided into several stages: Gonadotrophin ovarian stimulation begins once adequate
pituitary suppression is confirmed by baseline evaluation.3
• Pretreatment (also referred to as suppression or
downregulation) There are two types of GnRH agonist protocols: the long
protocol and the short protocol. The long protocol usually
• Ovarian stimulation
commences in the mid-luteal phase of the pretreatment
• Final egg maturation (or trigger)
cycle3,4 although it may begin up to 4 weeks before ovarian
• Egg retrieval
stimulation.2 This phase is sometimes referred to as the
• Fertilization of the eggs in the laboratory (in vitro)
‘downregulation’ or ‘suppression’ phase.
• Culturing of embryos
In the short agonist protocol, a GnRH agonist is usually
• Embryo transfer
administered from day 2 or 3 of the menstrual cycle once
• Luteal phase (often referred to by patients as the
‘two-week wait’) the baseline evaluation confirms a thin endometrium
and ‘quiet’ ovaries.5,6
Common preparations of GnRH agonist medications
Pretreatment phase (suppression include buserelin (Suprefact®) as a subcutaneous injection
or downregulation) and nafarelin (Synarel®) as a nasal spray.
Common preparations of GnRH antagonists include • In the agonist long protocol, a baseline evaluation is
cetrorelix (Cetrotide®) and ganirelix (Orgalutran®), which usually undertaken after 14 days of administering
are both administered as subcutaneous injections. medication.2
In our experience, the GnRH agonist long protocol is used • In the agonist short protocol and in the antagonist
more frequently. This may be because the antagonist protocol protocol, it is usually done in the first few days of the
is less practical logistically because fertility clinics are unable treatment cycle.2,5,6
to conveniently schedule or programme the treatment cycle. The baseline evaluation involves a transvaginal scan to
It may also be because older research suggested better preg- check the ovaries for cysts and to measure the thickness
nancy rates with the agonist protocol. However, a 2011 of the uterine lining. Oestrogen levels in the blood are also
Cochrane review concluded that pregnancy rates are similar checked. Some clinics monitor the level of other hormones
for both GnRH antagonist and agonist protocols.7 Another (for example, FSH and/or progesterone). Ovarian stimula-
Cochrane review concluded that, in poor responders, the tion cannot be initiated if there are ovarian cysts >25 mm,
GnRH agonist long protocol resulted in fewer eggs when if the endometrium is too thick, or if the oestrogen level is
compared to the shorter GnRH agonist protocol or the GnRH 370 pmol/L (100 pg/mL).6
antagonist protocol.8 If the baseline evaluation shows that the woman has not
Table 9.1 summarizes the key differences between the fully downregulated, the GnRH agonist may be adminis-
GnRH agonist and antagonist analogues. tered for longer, the dose may be increased, or the treat-
ment cycle may be cancelled.
CLINICAL TIPS If appropriate downregulation of the pituitary gland and
ovarian suppression have been achieved, there are no large
IVF TREATMENT PROTOCOL cysts, and oestrogen levels are low, the patient is advised to
Ask your patient to provide you with a copy of her IVF start ovarian stimulation with gonadotrophins. The GnRH
treatment protocol. This will help you to more accurately agonist is continued (usually at half dose) until hCG
plan your acupuncture treatment. administration, or the GnRH antagonist is initiated on
day 5 or 6 of ovarian stimulation.2 Table 9.2 summarizes
the events during the pretreatment phase.
Baseline evaluation
A baseline evaluation is used to ensure the woman can
go ahead with ovarian stimulation. Evaluation is done in
TCM protocol
all protocols, but the intra-protocol timing is slightly Acupuncture treatment during the pretreatment cycle
different2: depends on the protocol used. If the long GnRH agonist
Agonist Antagonist
Mode of action After 10 days the pituitary store of gonadotrophins is Immediately binds to and blocks GnRH receptors on
depleted. The pituitary is desensitized the pituitary gland2
When their Usually on day 21 of pretreatment cycle. But can be up Day 5 or 6 of ovarian stimulation2
administration to 4 weeks before the treatment cycle, or on day 1 of
begins the treatment cycle (‘short protocol’)2
Disadvantages The long protocol is associated with the development Limited programming of cycles and consequently
of ovarian cysts and symptoms such as headaches and increased rate of weekend egg retrievals.9 This is
hot flushes that result from oestrogen deficiency4 because the stimulation starts on days 2 or 3 of
menstrual cycle and this is an unpredictable event.9
Increased risk of OHSS7
One way to avoid this is to use the oral contraceptive
pill in the menstrual cycle before the start of the
stimulation phase.9 However, a meta-analysis found
that pretreatment with oral contraceptive pill
significantly reduced rates of ongoing
pregnancy.9,10 Pretreatment with oestrogen is
another method of programming the
GnRH-antagonist cycles to tie in with the fertility
clinics logistical needs9
238
Acupuncture during ART Chapter |9|
239
Acupuncture for IVF and Assisted Reproduction
To be used in:
• Long GnRH agonist protocol
• GnRH antagonist protocol (with pretreatment medication)
When to provide acupuncture treatment Up to 4 weeks before the ovarian stimulation begins. But more commonly
beginning on day 21 of the pretreatment cycle
Timing and frequency Treat once a week until the start of ovarian stimulation
Needling method and techniques Manual acupuncture is usually adequate. Some acupuncturists recommend
not using any abdominal points to avoid thickening the endometrial lining.15
Our experience is that abdominal points do not normally interfere
with the pituitary suppression and do not usually cause the endometrium
to thicken
Main points prescription Nourish Yin, clear Heat, regulate Qi,16 Blood, emotion, and harmonize the Liver:
LIV3,16,17 P6,18 SP6,16 SP10,16,19 YINTANG
TCM acupuncture treatment modifications Headaches GB20,20 LI416,21
Hot flashes KID6, KID2, KID1,22 HE623
Insomnia HE7,23 P7,18 ANMIAN24
Fatigue ST36,16,25 HUANMEN24
To be used in:
• Short GnRH agonist protocol
• GnRH antagonist protocol (without pretreatment medication)
• Natural (unsuppressed) pretreatment cycle
When to provide acupuncture Menstrual cycle before the ovarian stimulation begins
treatment
Timing and frequency Weekly sessions during the first 3 weeks of the pretreatment cycle
Twice weekly during the last week of the pretreatment cycle (when the process of follicular
recruitment begins)
Needling method and Manual acupuncture is usually adequate during the first 3 weeks. Abdominal points are
techniques essential during the late luteal phase when the follicular recruitment begins.
Electroacupuncture and a heat lamp may be used during this phase
Main points prescription Pretreatment cycle days 1–5 (menses): invigorate, regulate Qi and Blood, tonify Kidney Jing
(Essence): SP4 + P6,26 LU7 + KID6,27 REN428
Pretreatment cycle days 5–14: nourish Blood and Yin: SP4 + P6,26 LIV8,17 SP6,19 HE6,23
KID3,22 LU7 + KID627
Pretreatment cycle days 14–16 (ovulation): tonify Jing (Essence), regulate Qi and Blood,
reinforce Yang: KID1,22 ST27,25 REN4,28 KID3,22 ZIGONG24
Pretreatment cycle day 16 until ovarian stimulation begins: Smith et al. consensus on
acupuncture points useful during ovarian stimulation.29 Using these points during the late
luteal phase of the pre-treatment cycle may help with follicular recruitment: SP4 + P6,
LU7 +KID6, ZIGONG, REN4, ST36, SP6, ST29
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Acupuncture during ART Chapter |9|
stimulation is between 150 and 300 IU of FSH per day.32 In Follicular growth
patients at risk of poor response, the starting dose of FSH A review by Baerwald et al. established that during ovarian
may need to be between 300 and 450 IU/day.32 Doses stimulation cycles ovulatory follicles’ mean growth rate is
higher than this are ineffective.32,33 1.64 0.02 mm/day.36 Interestingly, anovulatory follicles
There are three types of gonadotrophins:34 grow at the slightly faster rate of 1.85 0.04 mm/day,36
• Urinary extracts: Human Menopausal Gonadotrophins which is a little faster compared to a natural cycle
or hMG (menotrophin), usually contains FSH and (1.48 0.10 mm for ovulatory and 1.41 0.06 mm for
LH (ratio 1:1). Common preparations are Merional® anovulatory follicles).36 Thus, it is undesirable for follicles
and Menopur®. to develop too quickly or too slowly. It is also better if
• Purified urinary FSH extracts or FSH-P follicles are homogenous (similar) in size.37 Chapter 10
(urofollitropin). A common preparation is Fostimon®. discusses how to manage patients with poor responses
• Recombinant synthetic hormone or rFSH to ovarian stimulation and Chapter 11 discusses how to
(follitropin). A common preparation is Gonal-F®. manage patients with OHSS.
A 2011 Cochrane review evaluated the effectiveness of
different gonadotrophin formulations and concluded that Oestrogen levels
there is no significant difference between various prepara-
Each mature egg produces approximately 600–800 pmol/L
tions. Therefore, the choice of gonadotrophin medication
(163–218 pg/mL) of oestrogen.2,38 Peak serum oestrogen
should be based on availability and cost.35
levels of >9000 pmol/L (2500 pg/mL) are associated with
During the ovarian stimulation phase, patients continue
a high risk of developing OHSS.39
taking GnRH analogues (agonist or antagonist) in order to
stop premature LH surge and spontaneous ovulation.
Endometrial development
For the embryo to be able to implant, the endometrial
Patient monitoring lining needs to be of appropriate thickness and receptive to
Follicular and endometrial development is monitored by the embryo. The thickness of the endometrial lining during
transvaginal ultrasound. Monitoring usually begins on the late follicular phase needs to be at least 6–8 mm40 and
days 5–7 of the ovarian stimulation stage. Many clinics also can be up to 16–17 mm or, in some instances, even
check serum oestrogen levels. The monitoring may start thicker.41,42 The lining also needs to be trilaminar (triple
earlier in patients at risk of OHSS or poor ovarian response. layer) in appearance (Figure 9.1).
Typically, the scan is repeated every 1–3 days. Patients’ Implantation, clinical, and ongoing pregnancy rates are
response to stimulation medication is monitored; if neces- significantly increased if the endometrial lining is greater
sary, their dose of medication is adjusted. Monitoring also than 9–10 mm.41,43,44 Clinical pregnancy and live birth
helps ART consultants decide when the patient is ready for rates increase linearly with increasing thickness of the
egg retrieval. endometrium even after adjusting for age and embryo
241
Acupuncture for IVF and Assisted Reproduction
242
Acupuncture during ART Chapter |9|
243
Acupuncture for IVF and Assisted Reproduction
244
Acupuncture during ART Chapter |9|
Table 9.8 Acupuncture final egg maturation protocol Table 9.9 Summary of egg retrieval protocol
(optional)
What Follicles are aspirated under vaginal
Timing and One treatment session on the day happens ultrasound guidance. Aspirated fluid is
frequency between the trigger injection and examined for presence of eggs
egg retrieval
Medication Sedation, general anaesthetic, or
If logistically impractical to paracervical block. Gas and air can also be
administer treatment at this time (for used
example, because this day is on a
Antibiotics are given afterwards to reduce
weekend day), then:
the risk of post-surgical infection
• Do the treatment on the day of
trigger injection or Monitoring Patient is normally discharged home after a
• Apply semi-permanent needles few hours, unless there are complications
during the last acupuncture
session before the trigger
injection and ask the patient to
group that received manual auricular acupuncture or a
remove them before egg retrieval
group that received no acupuncture.68 Table 9.10 provides
Needling method Electroacupuncture and a heat lamp a description of the auricular electroacupuncture protocol.
and techniques are useful adjuncts Other acupuncture protocols have been used and have
Main points SP4 + P6, ZIGONG (EA), ST29 (EA), shown faster recovery times in patients who received
prescription SP10, SP6, ST36, LIV8, REN4, HE5, electroacupuncture.70,71
YINTANG
In vitro fertilization
overripe, atretic, luteinized, or with fractured zona.66 It is
If the eggs are fertilized by a conventional IVF method, they
important to note that no consensus exists in the field of
are placed in a culture dish with a large number of motile
ART medicine about egg scoring, and, therefore, it is a very
sperm (50,000–100,000 per mL). Sperm then attempt to
subjective scoring process.66 Eggs are considered mature if
they are in metaphase II (the second phase of maturation), fertilize the egg in a similar manner as would happen in
natural or in vivo fertilization.2
and the first polar body has been discharged.66 Immature
eggs can potentially be matured in the laboratory using In Intracytoplasmic Sperm Injection (ICSI), one sperm is
injected directly into each egg. Before a sperm is injected, it
In Vitro Maturation (IVM).
If fresh sperm is used for fertilization of the eggs, which is needs to be immobilized by removing its tail. With this
technique, it is not necessary for sperm to undergo capac-
the situation in the vast majority of procedures, then the
sperm sample is collected on the same day by masturbation itation and the subsequent acrosome reaction (which is
required for in vivo fertilization).2 A variant of ICSI called
or via assisted sperm retrieval methods (see Chapter 6). The
spermatozoa are then removed from the seminal fluid.2
Table 9.9 summarizes what happens during the egg
Table 9.10 Acupuncture analgesia for egg retrieval
retrieval procedure.
procedure
Acupuncture • Acupuncture needles (27 gauge,
TCM protocol protocol68 3 mm length) inserted in auricular
Research suggests that acupuncture can be used as an effec- points 57 (Uterus), 55 (Shenmen),
tive pain-relieving method during the egg retrieval proce- and 29 (Cushion/Occiput) on the
dure.67–69 However, in our experience, provision of dominant side
acupuncture pain relief may be difficult to achieve because • Needles are then covered by adhesive
many ART clinics prefer to use conventional methods of tape and connected to a miniature
pain relief. stimulator worn behind the ear
In cases where acupuncture analgesia during egg retrieval (P-Stim™, Biegler GmbH)
• Electroacupuncture stimulation:
can be used, acupuncturists should consider a treatment
continuous low frequency with
protocol by Sator-Katzenschlager and colleagues that has
constant current of 1 Hz biphasic,
been shown to produce significant pain relief. In this
2 mA applied half an hour before egg
RCT study, pain levels were significantly lower during retrieval procedure and finishing 1 h
and after the egg retrieval procedure in a group that received after the procedure
auricular electroacupuncture compared to pain levels in a
245
Acupuncture for IVF and Assisted Reproduction
246
Acupuncture during ART Chapter |9|
Embryo transfer and involving everything they have been through to get this
far. A woman usually feels very protective of her precious
Orthodox medical protocol cargo, and many women believe themselves to be pregnant
Embryos can be transferred into the uterus at the cleavage until proven otherwise.
stage (day 2 or 3 after egg retrieval) or at the blastocyst stage
(day 5 or 6 after egg retrieval).76
The embryo transfer procedure is relatively simple and is
INTERESTING FACTS
usually pain free although occasionally sedation or general BED REST OR NO BED REST FOLLOWING
anaesthesia may be required (for example, in cases of cer- EMBRYO TRANSFER?
vical stenosis). A partner or a family member may accom-
pany the woman. The patient is asked to have a full Women often worry that the embryos will fall out after the
bladder. The patient lies on her back (sometimes with embryo transfer. In the past, many clinics would leave
her legs in stirrups), and the doctor uses a speculum to women to rest in a horizontal position for 30 min or even
longer after the transfer. Some clinics still do so.
expose the cervix. The cervix may be cleaned with sterile
However, research shows that, in 94% of cases, there is
solution or culture medium. The embryologist will load
no movement of embryos on standing immediately after the
the embryo(s) into a fine, soft catheter for the doctor or
embryo transfer; in 4% of cases, there is <1 cm movement;
nurse to transfer through the vagina and cervix into the and, in only 2% of cases, there is >4 cm movement.82
womb. Clinicians will have different preferences as to
exactly where in the uterus they transfer the embryos. Most
aim to place the embryo(s) 1–1.5 cm under the uterine fun-
dus. Some doctors use an abdominal or transvaginal ultra-
TCM protocol
sound to help to position the embryo(s) in the uterus. Acupuncture treatment around the time of embryo transfer
Using an ultrasound-assisted approach has been shown has been shown to increase pregnancy rates83–86 although
to increase IVF success rates.77,78 not all studies demonstrate this effect.87–90
The catheter is then removed and checked under the Many studies use the points prescription based on the
microscope to ensure the embryo(s) have been transferred. Paulus et al.84 study, in most cases without adequate
The transfer process can take around 15 min. When the acupuncture treatment during the other stages of IVF (see
embryo transfer is completed, the patient may be left to rest section ‘Critique of acupuncture and IVF research’).
for 15–20 min, although not all clinics recommend this However, the Paulus protocol does appear to be helpful
recovery period. and is preferred by patients who learn of it from the Inter-
Often couples are given a photograph of the embryos or net. The Paulus protocol treatment on the day of embryo
shown the embryos that will be transferred on a screen transfer can be individualized based on a patient’s TCM
before they are loaded into a catheter. If an ultrasound is diagnosis. Table 9.12 summarizes acupuncture treatment
used, patients and their partners may be given the opportu- protocols that can be used on the embryo transfer day.
nity to watch the transfer as it progresses. A white dot is seen We would like to note that there is no need to be too rigid
on the screen once the embryos have been discharged into about this treatment protocol. In our experience, treating
the uterus. This dot is an air bubble, which is loaded inside patients within 24 h of embryo transfer is often just as effec-
the catheter before the embryos and helps the clinician see tive as doing the treatment 25 min before and after the
exactly where the embryo(s) have been placed. transfer.
Occasionally, there may be difficulties during the embryo
transfer – for example, embryos may become stuck in the
catheter, the cervix may be too tight for the catheter to be Critique of acupuncture and IVF research
inserted, or the woman may be too uncomfortable. Diffi- Despite there being over 40 published clinical trials on acu-
cult transfers have been shown to reduce the IVF success puncture and IVF13 and at least 10 systematic reviews, it is
rate.79–81 Chapter 10 discusses difficult embryo transfers still not clear to what extent acupuncture influences IVF out-
in greater detail. Any surplus embryos can be cryopreserved comes. Earlier systematic reviews suggested benefits with the
(frozen) to be used in future Frozen Embryo Transfer (FET) use of acupuncture and IVF. More recent reviews (with one
cycles. In some countries, freezing embryos is illegal. exception) do not support this beneficial relationship.
The day of the embryo transfer can have a great emo- A systematic review and meta-analysis by Manheimer
tional impact on a couple. On the morning of the embryo et al. of seven trials (1366 participants) concluded that acu-
transfer day, many couples worry that the embryo(s) will puncture administered at the time of embryo transfer
not ‘make it’. They may also be very anxious about arriving improves live birth rates.92
at the ART clinic on time, especially if the clinic is some dis- A Cochrane review by Cheong et al. analysed 13 RCTs
tance away from them. Some women worry about the and concluded that acupuncture performed on the day of
embryo transfer procedure and possible discomfort. When embryo transfer significantly increased live birth rates.14
the embryo(s) are transferred, this can be a very moving A systematic review and meta-analysis by El-Toukhy et al.
experience for the couple, a climax of emotions about of 13 trials (2500 participants) found that acupuncture did
247
Acupuncture for IVF and Assisted Reproduction
Table 9.12 Acupuncture treatment protocols for the use around the time of embryo transfer
Timing On the day of embryo transfer (day 2, 3, or 5 post egg retrieval). If logistically impractical, the treatment
can be carried out within 24 h of the transfer
Paulus et al. 200284 Treatment 1: 25 min before embryo transfer
P6, SP8, LIV3, DU20, ST29
Left ear: Shenmen (55), Zigong (58)
Right ear: Neifenmi (22), Naodian (34)
Treatment 2: 25 min after embryo transfer
ST36, SP6, SP10, LI4
Right ear: Shenmen (55), Zigong (58)
Left ear: Neifenmi (22), Naodian (34)
Method
Strong de qi sensation was obtained during the initial insertion and again 10 min later. Needles were
retained for 25 min
Dieterle et al.91 Treatment 30 min after embryo transfer
REN4, REN6, ST29, P6, SP10, SP8. Herbal seeds placed on ear points Shenmen (55), Zigong (58),
Neifenmi (22), Pizhixia (33)
Omodei et al.86 Treatment 1: 25 min before embryo transfer
YINTANG, LI4, ST36, SP6, LIV3
Treatment 2: 25 min after embryo transfer
‘Shenmen, Uterus, Kidney, and Heart’
Other acupuncture Before transfer (2- or 3-day- Empiric SP4 + P6, LIV3, LI4, REN4, SP6, ST36, SP10,
prescriptions old embryos) prescription ZIGONG, ST29, YINTANG
Blood Deficiency Add BL17, BL15, BL18, BL23 moxa
Kidney Yang Add KID3, REN12, KID7 moxa
Deficiency
Blood Stasis Add SP8
Dampness Add SP9, ST28, REN3, LIV5, BL20, SP3 moxa
Heat/Fire Add LIV2, LIV4, ST45, SJ5
After transfer (2- or 3-day-old Empiric REN4, REN6, KID7, ST36, DU20
embryos) prescription
Blood Deficiency Add LIV8, P6, HE6
Kidney Yang Add DU4, BL23, BL52 moxa
Deficiency
Dampness Add BL20, SP5 moxa
Blood-Stasis Add SP10
Heat/Fire Add LI11, P7, KID8
After transfer (day 5 Empiric REN12, REN6, DU20, HE5
blastocyst transfer) prescription
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Acupuncture during ART Chapter |9|
not have a significant effect on clinical or live birth rates.93 in many participants; therefore, this needle may not be an
The authors updated their results in 2009 after publication inert placebo.96,104,105
of another RCT and confirmed their original findings.94 In their meta-analysis, Zheng et al. found that acu-
A systematic review and meta-analysis by Qu et al. of 17 puncture improves clinical pregnancy rates and live birth
trials found no evidence of significant benefit with the use rates only if the studies that do not use the Streitberger
of acupuncture during IVF or ICSI.95 sham needle are included in the analysis. The authors con-
A systematic review and meta-analysis by Zheng et al. of clude that the Streitberger control may not be inactive.47
24 trials (5807 participants) found that acupuncture signif- However, some experts feel that removing the Streitberger
icantly improved clinical pregnancy rates but not live birth control is not scientifically valid.99 Other placebo acu-
rates. When the authors excluded studies that used the puncture devices are being developed.102 Perhaps in time
Streitberger sham needle, acupuncture was shown to have these may offer a better control technique.
a statistically significant influence on live birth rates, espe-
cially if, in addition to acupuncture at embryo transfer,
Individualization of treatment
acupuncture was also administered during the ovarian
stimulation phase and egg retrieval.47 Most acupuncture studies use fixed protocols.13 This could
A systematic review and meta-analysis by Manheimer be compared to IVF consultants prescribing the same dose
et al. of 16 trials (4021) participants found that acupunc- of FSH medication to women with good ovarian reserve
ture offers no benefit for IVF.96 and women with poor ovarian reserve. In clinical reality,
An updated Cochrane review by Cheong et al. after patients are treated on an individual basis.
analysis of 20 RCTs concluded that acupuncture had no However, the studies also need to be reproducible100 and
effect on live birth rates.97 comparable.95,98 Therefore, fixed detailed (individualized)
The reason why the reviews produce such mixed results protocols should be used in future studies,100 and the Stan-
might be in part caused by the different inclusion and dards for Reporting Interventions in Clinical Trials of Acu-
exclusion criteria they used for selecting trials for analysis. puncture (STRICTA) guidelines should be followed when
Another reason is the methodological limitations of many reporting acupuncture intervention.106
trials.98 In this section, we outline some of the issues with
the research on acupuncture treatment and IVF. Outcome measures
Many acupuncture studies report limited outcome mea-
sures.100 For example, some only report implantation rates.
Sample size All relevant outcome measures should be reported in future
Most IVF acupuncture studies are relatively small and, IVF studies, including clinical pregnancy, biochemical
therefore, may be underpowered.99,100 In their review pregnancy, ongoing pregnancy, implantation rate, live
paper, Meldrum et al. state that in order to achieve more birth rate, and miscarriage rate.95
meaningful results, future studies need to recruit at least Acupuncture treatment may also potentially have a posi-
996 and potentially as many as 3829 participants for each tive effect on other outcomes such as emotional and physical
of the acupuncture and control groups.99 El-Toukhy and well-being of patients undergoing IVF treatment, ovarian
Khalaf state that 2300 women need to be recruited in each response to stimulation, total amount of medication used,
arm of future studies investigating the effect of acupuncture number of mature eggs retrieved, thickness of the endome-
on clinical pregnancy rates and an even greater number of trial lining, fertilization rate, embryo grades, and discomfort
women should be recruited for studies using live birth rate during the embryo transfer procedure. Based on our inter-
as an outcome measure.101 pretation of the literature, we believe that future studies
should consider all potential outcome measures.
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Acupuncture for IVF and Assisted Reproduction
stimulation may help to recruit more follicles, which could Key influence 3: recruitment of follicles (late
potentially lead to better outcomes. luteal/early follicular phase)
n In response to rising FSH levels, follicular
recruitment begins either at the end of the luteal
Timing of acupuncture treatment phase115 (in an unsuppressed cycle) or in the first few
The majority of studies administered acupuncture around days of the stimulation phase at the time when
the time of embryo transfer. We are unaware of any acu- women begin to inject gonadotrophins. We would
puncture IVF studies using acupuncture in the 3–6 months’ posit that administering acupuncture treatment at
preparation phase preceding IVF. This seems surprising the end of the luteal phase (in unsuppressed cycles)
because, ultimately, the outcome of IVF depends on the and at the beginning of the follicular or stimulation
quality of the eggs,109,110 sperm,111–113 and the resulting phase may potentially influence follicular
embryo.114 Endometrial thickness and uterine receptivity recruitment, resulting in a greater pool of follicles
are also highly important for IVF success.41,43,44 available for stimulation.
As Figure 9.3 shows, the timeframe over which the eggs, Key influence 4: endometrial lining (stimulation phase)
sperm, and endometrium develop is many months before n The endometrium develops during the stimulation
the embryo transfer day. Administering acupuncture phase. Therefore, in order to influence the
treatment only on the day of embryo transfer (as has been development of the endometrium, frequent
done by most studies) may be considered undertreatment acupuncture treatments should be administered
because, by this stage, all key elements essential for a good- during the stimulation phase. There is preliminary
quality embryo to develop and likely to influence the research evidence suggesting that acupuncture may
outcome are beyond the stage where they can be improved positively influence endometrial development.48
by acupuncture. Key influence 5: follicular response to gonadotrophin
The key stages influencing IVF outcome are as follows: stimulation
Key influence 1: follicular development (6 months n Colour Doppler studies show that follicular
delivery of reproductive hormones and nutrition to shows that acupuncture improves utero-ovarian
the follicles. Colour Doppler studies show that the blood flow.50,51,64,65 Improved utero-ovarian blood
development of follicles is directly correlated with flow may improve follicular blood perfusion during
their circulatory supply.115,116 the stimulation phase.
n Limited human and animal research shows that n More research is necessary to investigate further to
such an effect can only be achieved by treating men acupuncture improves ovarian blood flow (see above),
during the 3 months preceding the day of sperm one of the world’s leading experts on folliculogenesis,
collection. Alain Gougeon, believes that if the acupuncture
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Acupuncture during ART Chapter |9|
IVF phases Preparation phase Pretreatment phase Stimulation phase Luteal phase
(3–4 months) (up to 4 weeks before (on average 12 days) (the last 2 weeks)
stimulation)
Endometrium develops
during the stimulation phase.
Endometrial
4 development
Acupuncture during this
phase may increase its
thickness and quality.
Acupuncture
between
hCG trigger
Final egg and egg
6 maturation retrieval may
help with
final egg
maturation.
Acupuncture
may reduce
7 Egg retrieval pain during
egg retrieval
procedure.
Acupuncture
on the day of
embryo
Embryo
8 transfer transfer (2, 3,
or 5 post egg
retrieval) may
be used.
Acupuncture
during implantation
window (days 4–8
9 Implantation post egg retrieval)
may help with
embryo
implantation.
treatment is delivered precisely between the LH surge n As already discussed, acupuncture has been shown to
and ovulation, it could potentially reinforce the natural improve blood supply to the uterus, and acupuncture
increase of ovarian vascularization induced by the LH could therefore potentially influence implantation if
surge (A. Gougeon, personal communication). administered on days 4–8 after egg retrieval.
Gougeon also believes that the use of acupuncture at In conclusion, treating women only on the day of embryo
this time could be especially appropriate in the transfer (as the majority of studies seem to do) fails to maxi-
management of older women. Because hCG trigger mize the potential benefit acupuncture could offer. In com-
medication mimics the action of LH, we would parison to conventional IVF, the use of acupuncture only
hypothesize that a similar response is likely if on the day of embryo transfer may be compared to
acupuncture treatment is administered between the carrying out an embryo transfer procedure without
trigger injection and egg retrieval. adequate ovarian stimulation. The results in both instances
n Our clinical experience confirms that acupuncture may well be suboptimal.
treatment on the day between the trigger injection
and egg retrieval appears to greatly affect egg
Stress of acupuncture treatment
maturation. The value of administration of
acupuncture treatment at this stage is supported by The other issue with fixed protocols focusing on the day of
other authors.13,29 embryo transfer is that their use could potentially generate
Key influence 7: pain relief during egg retrieval (optional) an unnecessary stress in patients.
n Acupuncture has been shown to be an effective pain
Meldrum et al. in their review paper suggest that in some
relieving method during the egg retrieval instances the provision of acupuncture treatment on
procedure,68 and it may aid with postsurgical embryo transfer day can be detrimental rather than benefi-
recovery.67,70,71,123 However, there is no evidence cial. They suggest examples such as procedurally induced
that administering acupuncture on the day of egg stress caused by strong acupuncture needling technique
retrieval influences conception rates. or a stress response induced on the day of embryo transfer
Key influence 8: embryo transfer (days 2, 3, or 5 after caused by anxiety associated with logistical and practical
egg retrieval) issues such as travelling to and from an acupuncture
n The majority of the published research on
clinic for embryo transfer acupuncture protocols to be
acupuncture and IVF has been done to study the administered.99
effect of administering acupuncture during the Manheimer et al. in their systematic review and meta-
embryo transfer phase. The effect of acupuncture on analysis hint at a similar opinion, stating ‘Although it
the day of embryo transfer may have a positive was not a statistically significant subgroup finding, there
influence on IVF outcomes. However, research was a trend suggesting that acupuncture administered
results are mixed and equivocal (Critique of on-site of the IVF clinic had more positive effects than
acupuncture and IVF research). acupuncture administered off-site of the IVF clinic’.96 The
n It is unclear exactly what the administration of
authors, however, did acknowledge that their opinion
acupuncture treatment on the day of embryo transfer was based only on the study by Craig et al.127
is likely to influence because eggs, sperm, embryos, In our opinion too rigid an adherence to the timing of
and the endometrium are already developed. the administration of acupuncture protocols to some
Logically, the only aspects acupuncture may help patients who may have a tendency to be anxious may
with on the day of embryo transfer are the reduction indeed cause stress. Other authors also acknowledge the
of uterine contractions and the reduction of stress detrimental aspect of trying to adhere to a rigidly applied
levels, provided that a woman does not develop a protocol.13
stress response because of a rigid schedule of
acupuncture treatments. It is also possible that Confounding factors
acupuncture may modulate a woman’s immune Many studies fail to control for confounding factors, such
response to the embryo. as weight, nutrition, alcohol consumption, smoking, and
Key influence 9: implantation and endometrial medical factors such as hormonal and ovarian status.
receptivity (days 4–8 post egg retrieval) Future studies should aim to control for such confounding
n In controlled ovarian stimulation cycles, the factors.
implantation window is in the range of 4–8 days post
egg retrieval.124 Good utero-ovarian blood flow during
the peri-implantation period influences conception What about men?
rates in women undergoing IVF.125 A delay in achieving Male factor contributes to up to 40% of infertility cases.128
adequate uterine perfusion may affect endometrial Male factor subfertility may also lead to implantation
receptivity.125 It has been found that good uterine failure111–113 and miscarriages.129,130 Most if not all studies
blood supply on the day of hCG administration investigating the effect of acupuncture on IVF outcomes
is associated with conceptions in IVF patients.126 treat either a male or a female partner. We are unaware
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Acupuncture during ART Chapter |9|
of a single trial where a couple is treated as a unit. It would production, which is necessary for adequate luteal phase
be interesting to see if treating both partners in preparation support. Therefore progesterone supplementation is
for and during IVF would produce better outcomes. required because it is important for implantation and to
reduce uterine irritability.6
The supplementation with progesterone usually begins
Practical considerations in treating patients on the evening after egg retrieval. Progesterone can be
on the day of embryo transfer administered in the following ways:6
In many cases, it is difficult to know in advance when the • Progesterone in oil (for example, 50 mg IM daily)
transfer of the embryo will take place, especially if there are • Oral micronized progesterone (for example,
not many embryos. Patients get regular telephone calls 600 mg daily)
updating them on how their embryos are developing and • 8% progesterone vaginal gel (for example, 90 mL daily)
when the transfer is likely to take place. In some cases • Micronized natural progesterone in vaginal tablets (for
patients are asked to come in for the embryo transfer example, 300 mg daily)
procedure at very short notice. There is no evidence that any one route of progesterone
Many patients are aware of the embryo transfer acupunc- administration is more effective than any other. Intramus-
ture treatment protocols. Patients often expect their acupunc- cular administration was found to be more effective in a
turist to perform them on demand. Consequently, fertility 2002 meta-analysis,131 but a 2009 meta-analysis found
acupuncturists may need to be available at short notice for that outcomes were similar for vaginal and intramuscular
the provision of embryo transfer treatments. This poses a progesterone administration.132
practical problem: potentially being on call 7 days a week, Alternatively, hCG supplementation may be used. Typi-
365 days a year. For the acupuncturists specializing in treating cally 250 mg of recombinant hCG is administered subcuta-
patients with fertility issues this means that the busier their neously, or 2500–5000 IU is injected intramuscularly
fertility practice is, the more likely they are to work on days 1 week after the ovulation trigger. Progesterone and hCG
off (including at the weekend). Planning family and social life luteal support produce similar results, but hCG supple-
therefore often revolves around, and is constrained by, being mentation significantly increases the risk of OHSS.6
available to provide ‘transfer appointments’. Oral oestrogen can be added to progesterone during the
One way to manage this type of workload is to team up luteal phase in GnRH agonist cycles. For example, adding
with another acupuncturist who specializes in infertility. 4 mg of oral oestradiol to progesterone supplementation
The acupuncturists do not need to work in the same clinic, has been shown to significantly increase the pregnancy
as long as they are a reasonable driving distance away from and implantation rates and has decreased the miscarriage
each other. This should enable the team members to sup- rate compared with the use of progesterone monother-
port each other, either on a rota or an ad hoc basis. apy.133 A 2011 Cochrane review found that there was
In embryo transfer acupuncture research studies, treat- a significant increase in the clinical pregnancy rate when
ment is often provided within 25 min or so before and after progesterone was combined with transdermal or oral oes-
the embryo transfer. Since publication of Paulus 2002 pro- trogen. But no effects were found with vaginal oestrogen
tocol, there has been a lot of debate within the acupuncture administration.134
profession about the importance of timing of the provision Table 9.13 summarizes what happens during the luteal
of acupuncture embryo transfer treatment. phase.
Many expert fertility acupuncturists consider that the tim-
ing is not critical, and the embryo transfer acupuncture treat-
ments can be done on the day before or day after the transfer,
particularly if being rigid with the timing of the transfer treat-
ment creates an unnecessary stress for patients.99 One study CLINICAL TIPS
showed lower pregnancy rates in patients who received acu- PROGESTERONE SUPPORT
puncture treatment compared to a control group. The acu-
puncture patients in this study experienced a stressful Some ART units withdraw progesterone support after a
journey to and from the acupuncture clinic in order to be positive pregnancy test whilst other units continue
treated within 25 min of their embryo transfer, which may prescribing progesterone until around 12 weeks’ gestation
or even later.
have influenced the outcome.13,127
In the authors’ experience, patients with a diagnosis
of Yang Deficiency or a history of a miscarriage associated
Luteal phase (the ‘two-week wait’) with Yang Deficiency will benefit from being on luteal
support until 12 weeks’ gestation. If such support is not
Orthodox medical protocol provided by the ART clinic, acupuncture and
moxibustion to support Yang is essential throughout
GnRH analogs (agonist and antagonists) that are used in
the first 12 weeks.
IVF interfere with LH production. This affects progesterone
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Acupuncture for IVF and Assisted Reproduction
254
Acupuncture during ART Chapter |9|
Table 9.14 Luteal phase (‘two-week wait’) acupuncture protocol (from the day of embryo transfer
to pregnancy test day)
Timing and frequency Session 1: during implantation window (4–8 days post egg retrieval)124
Session 2: halfway between session 1 and proposed pregnancy test date
Main points prescription Reinforce Yang, nourish and warm Blood, tonify the Spleen and Kidneys, calm the Shen
(Spirit) to aid implantation and prevent miscarriage136:
KID3, KID7, ST36, SP3, REN4, REN6, DU20, YINTANG moxa
TCM acupuncture treatment Liver Qi Stagnation Regulate Qi and Blood: LIV8,17 BL1854
modifications (also see
Blood-Stasis Eliminate Blood-Stasis, invigorate Blood: SP10,19 SP4 + P619
Chapter 5)
Dampness Resolve Dampness: SP9,19 REN928 moxa
Cold Warm Cold: DU4,55 REN828 moxa
Kidney Jing (Essence) Tonify the Kidney: BL23, BL5254 moxa
Deficiency
Blood Deficiency Nourish Blood: LIV8,17 REN1228 moxa
Qi Deficiency Tonify and regulate Qi: HE523
Orthodox medical conditions Advanced maternal age Tonify Kidney Jing (Essence), nourish Blood, regulate the
modifications Chong and Ren Mai (Penetrating and Conception Vessels):
KID13 + KID12,22 LU7 + KID6,53 SP4 + P619 moxa (also see
Chapters 10 and 12)
History of miscarriage(s) Tonify Kidney Jing (Essence), Qi, Yang and Blood: BL23, BL52,54
KID2,22 BL2054 moxa (also see Chapter 12)
PCOS Raise Qi, regulate the Spleen: TITUO,24 SP919 (also see
Chapter 8)
Hypothyroidism Regulate Qi and Blood: REN12,28 HE523 (also see Chapter 8)
Hyperthyroidism Clear Heat/Fire, nourish Blood: LIV2,17 P7,18 LIV8,17 HE323 (also
see Chapter 8)
Endometriosis Regulate Blood: KID5,22 REN3,28 SP10,19 SP4 + P619 (also see
Chapter 8)
OHSS Regulate fluids, Qi, and Blood: SP9,19 REN928 (also see
Chapter 11)
Immune issues Regulate Qi and Blood: ST36,25 SP1019 (also see Chapter 12)
Thrombophilia and other Promote free flow of Qi and Blood: SP4 + P6,19 ST3025 (also see
clotting conditions Chapter 12)
Case study
Continued
255
Acupuncture for IVF and Assisted Reproduction
Case study—cont’d
In view of Fiona’s and Jack’s fertility and ART history, I ® Pretreatment phase: Fiona’s cycle was supressed
recommended that Jack should also have acupuncture with GnRH agonist, which she began on day 21 of
treatment. the cycle preceding the IVF treatment cycle. One
acupuncture treatment was administered 2 days
Jack’s Manifestations before stimulation: LU7 +KID6, SP6, SP3, LIV2,
Feeling hot, especially at night, nightsweats, thirsty, back pain, ST29, ZIGONG, REN4. A heat lamp was placed over her
scanty urination. Pulse: very weak on all positions. Tongue: abdomen.
slightly pale. Jack also had family history of male factor ® Stimulation phase prescription: LU7 + KID6, SP4 + P6,
subfertility. ST29, ZIGONG, REN4, SP6, LIV3. A total of three sessions
Fiona’s Manifestations were administered. The endometrium reached at least
8 mm (Fiona was not sure), and on the day of hCG trigger
Red face and neck, irritability, frustration, extreme injection she had five follicles between 13 and 18 mm
tiredness, tendency to worry. Menstrual cycles were regular on the right side and one on the left.
28 days and bleeding lasted 6–7 days (including 1–2 days of
® Egg retrieval and fertilization: 4 mature eggs were retrieved
premenstrual spotting). Dull abdominal ache persisted
and all were fertilized using ICSI.
throughout the cycle, which was worse during menses. Her
tongue was red with heat spots, and her pulse was rapid, ® Embryo transfer: one top-grade embryo was transferred on
overflowing. day 2 and two top-grade embryos were frozen. Paulus
et al.84 embryo transfer acupuncture protocol was done
TCM Diagnosis (Jack) before and after the transfer.
Kidney Yin Deficiency (primary syndrome) ® Luteal phase: acupuncture treatment was done on day 6
post egg retrieval (to coincide with implantation stage).
TCM Diagnosis (Fiona) Points used were: HE7, LIV2, SP3, KID7, KID9.
® Liver Fire The pregnancy test was positive and pregnancy progressed to
® Spleen Qi Deficiency full term.
Case study
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Acupuncture during ART Chapter |9|
Case study—cont’d
257
Acupuncture for IVF and Assisted Reproduction
258
Acupuncture during ART Chapter |9|
rates. This section describes common FET protocols and • Regulate the menstrual cycle to ensure that the ART
how to manage patients undergoing FET. treatment cycle can be started on schedule.
• Support the patient emotionally.
• Continue to address any underlying TCM pathology.
Pretreatment (downregulation A 2008 Cochrane review found that pretreatment with
or suppression) GnRH agonist in women undergoing FET significantly
increases live birth rates.140
Orthodox medical protocol Tables 9.15 and 9.16 summarize TCM acupuncture treat-
Protocols vary significantly amongst fertility clinics. Some ment during the FET pre-treatment cycle.
clinics prefer not to do any ovarian suppression. Others reg-
ulate the menstrual cycle with GnRH agonist to supress FSH
and LH production. The protocol for suppression with
Follicular phase (endometrium
GnRH agonist is described in detail in section ‘In vitro
fertilization’. preparation)
Orthodox medical protocol
TCM protocol This stage of FET focuses on adequate endometrial prepara-
tion. The main aim of the endometrial preparation phase is
Acupuncture treatment during the pretreatment cycle will
to synchronize the age of the embryo (after it has been
depend on the protocol chosen by the fertility clinic. If
thawed) with the correct stage of endometrial develop-
the long GnRH agonist is used with the purpose of suppres-
ment.140 Endometrial preparation can be natural or medi-
sing gonadotrophin secretions by the pituitary, the aim of
cally controlled.
acupuncture treatment administration will be to:
• Treat the adverse effects of medication, which for
GnRH agonist tend to be quite severe because they Natural FET
induce low oestrogen levels; this may cause hot flashes, Regular ultrasound scans are undertaken to monitor follic-
perspiration, headaches, mood fluctuations, insomnia, ular and endometrial development and to help with start-
nervousness, sore breasts, and fatigue.2 ing LH tests at the correct time. The endometrial lining
• Support the patient emotionally. thickness should be at least 7–8 mm,44,141–143 but ideally
• Continue to address any underlying TCM pathology. it should be 9–14 mm.44 Cycles may be cancelled if the
With the short GnRH agonist or in cycles with no suppres- endometrium is too thin or if a woman ovulates
sion, acupuncture during the pretreatment cycle aims to: prematurely.144
To be used in:
• Long GnRH agonist protocol
When to provide acupuncture treatment Up to 4 weeks before the FET cycle begins. But more commonly beginning on day
21 of the pretreatment cycle
Timing and frequency Treat once a week until FET cycle begins
Needling method and techniques Manual acupuncture is usually adequate. Some acupuncturists recommend not
using any abdominal points to avoid thickening the endometrial lining.15 Our
experience is that abdominal points do not normally interfere with the pituitary
suppression and do not usually cause the endometrium to thicken
Main points prescription Nourish Yin, clear Heat, regulate Qi,16 Blood, emotion, and harmonize the Liver:
LIV3,16,17 P6,18 SP6,16 SP10,16,19 YINTANG
TCM acupuncture treatment modifications Headaches GB20,20 LI416,21
Hot flashes KID6, KID2, KID1,22 HE623
Insomnia HE7,23 P7,18 ANMIAN24
Fatigue ST36,16,25 HUANMEN24
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Acupuncture for IVF and Assisted Reproduction
To be used in:
• Short GnRH agonist protocol or
• Natural (unsuppressed) pretreatment cycle
When to provide acupuncture Menstrual cycle before FET cycle
treatment
Timing and frequency Weekly sessions
Needling method and Manual acupuncture is usually adequate during the first 3 weeks
techniques
Main points prescription Pretreatment cycle days 1–5 (menses): invigorate, regulate Qi and Blood, tonify Kidney Jing
(Essence): SP4 + P6,26 LU7 + KID6,27 REN428
Pretreatment cycle days 5–14: nourish Blood and Yin: SP4 + P6,26 LIV8,17 SP6,19 HE6,23 KID3,22
LU7 + KID627
Pretreatment cycle days 14–16 (ovulation): tonify Jing (Essence), regulate Qi and Blood,
reinforce Yang: KID1,22 ST27,25 REN4,28 KID3,22 ZIGONG24
Pre-treatment cycle day 16 until FET cycle begins: SP4 + P6,26 ZIGONG,24 REN4,28 ST36,25
From around day 9 or 10 plasma or urine LH levels are or 10.145 When the endometrium is 7–9 mm thick, proges-
checked until the LH surge is detected. In some natural FET terone supplementation is added to initiate secretory
cycles ovulation is medically triggered by hCG injection.140 changes in the endometrium.44,144–146 As with natural
In one study the criteria for triggering with hCG was that FET, an endometrial lining that is <7–8 mm thick may
the leading follicle was >17 mm in diameter, serum oestra- result in a cancellation of FET.44,141–143 FET may also be
diol level >150 pg/mL, and serum progesterone level cancelled due to premature ovulation.144
<1 ng/mL.143 In women with functional ovaries, oestrogen medication
Natural cycles are suitable for women with regular men- may be insufficient to fully suppress the development of
strual cycles and who regularly ovulate.140 The disadvan- the dominant follicle. Therefore, the GnRH agonist may
tage of a natural cycle is that ovulation may not always be used in addition to oestrogen to achieve suppression
occur or it may be difficult to time FET. of ovarian function and prevent a premature LH surge
and ovulation.140,144,147 This approach has been shown
to significantly increase live birth rates.140
Controlled FET
Controlled cycles have the advantage of greater predict-
In a controlled FET cycle, the endometrium is prepared by ability and flexibility. Thus cancellation rates are lower,
administering exogenous oestrogen, which causes pro- especially if GnRH agonist is used.140
liferation of the endometrium.144 Administering oestro-
gen from day 1 of the menstrual cycle suppresses FSH
levels and therefore stops a dominant follicle developing, TCM protocol
thus preventing spontaneous ovulation. Oestrogen is usu-
Acupuncture treatment during the follicular phase of FET
ally administered in tablet form, transdermal patches, or
may help with endometrial development. Table 9.17 sum-
vaginal rings or vaginal tablets.140 One commonly used
marizes the TCM acupuncture treatment during endome-
oestrogen preparation in FET is Progynova®, which can
trial preparation in a FET cycle.
be prescribed in a tablet form or patch form. The dose
used can be between 2 and 8 mg/day and is usually
increased gradually until the endometrium is suffi-
ciently thickened.140 In cases where the lining fails to
Ovulation
thicken, oral oestrogen may be replaced by vaginal Orthodox medical protocol
oestrogen.145
Regular ultrasound scans are performed to monitor Natural cycle
endometrial development. The scans start around day 9 Spontaneous ovulation occurs in a natural FET cycle.
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Acupuncture for IVF and Assisted Reproduction
of various ovulation-inducing medications was explored. surge and take place every day or every other day for 5 days.
This section focuses on the management of patients under- Ovulation is confirmed by visualization of a collapsed
going ovulation induction treatments. follicle on transvaginal ultrasound or by checking the
mid-luteal phase progesterone levels.
The pregnancy rate is around 10–30% per ovulatory
Follicular phase cycle.34 Up to six cycles may be performed and the overall
Ovulation induction with Clomiphene chance of pregnancy is around 75%.153
Citrate
Clomiphene Citrate (CC) is administered as a 5-day course Ovulation induction with FSH
therapy starting on days 3, 4, or 5 of the menstrual cycle.6 Ovulation induction with FSH is a second-line treatment
The dose administered ranges from 50 to 150 mg/day.6 for induction of ovulation in patients with WHO grade I
A higher dose may be needed in obese patients.6 However, ovulation disorders (see Chapter 8). It can be used if the
most women respond to a dosage range of between 50 mg/ LHRH (GnRH) pulse pump system fails to induce ovulation.
day (52%) and 100 mg/day (22%).151,152 Amenorrhoeic Fifty to 75 units of FSH gonadotrophins are injected
patients will benefit from an oestrogen- or progesterone- subcutaneously daily. If the follicular development is poor,
induced withdrawal bleed to prime oestrogen receptors.6 the dose can be increased incrementally by 37.5 units.
Follicular development can be monitored by transvagi- The maximum recommended dose is 225 units/day. GnRH
nal ultrasound, usually with one or two scans that start antagonist may be administered to stop premature
on day 8 or 9 of the menstrual cycle.6 Urinary LH surge kits LH surge.
can be used to detect pre-ovulatory LH surge, indicating Follicular growth is monitored by a series of ultrasound
that ovulation is likely to follow 12–24 h later.6 Intercourse scans. Oestrogen levels are monitored after 3–4 days of
should begin around the time of LH surge and take place stimulation.6 Ovulation is triggered by a single hCG injec-
every day or every other day for 5 days. tion of 5000–10,000 IU intramuscularly when the follicles
Ovulation is confirmed if a collapsed follicle can be seen are 15–18 mm in size.6 Intercourse should take place every
on transvaginal ultrasound or alternatively by checking day or every other day for 5 days, starting with the night of
mid-luteal phase progesterone levels.6 A level of the hCG trigger injection.6 This treatment protocol is 90%
>9.54 nmol/L (3 ng/mL) is considered to be evidence that successful in achieving ovulation and has 50% pregnancy
ovulation has occurred. Levels of 31.8 nmol/L ( 10 ng/ rate. It can be repeated for a total of 6–8 cycles.6,153
mL) are considered a sign of healthier luteal phase.152
The administration of CC can be repeated for up to 6
cycles.6 If there are significant adverse effects such as TCM protocol
headaches, abdominal pain, or visual disturbances, the
CC treatment may need to be discontinued at an earlier
Pretreatment cycle
than planned date.6 CC has an anti-oestrogenic effect Follicular recruitment normally begins when FSH rises at
and in some women can cause thickening of cervical mucus the end of the luteal phase of the cycle preceding the ovu-
and/or inhibit endometrial development resulting in a thin lation induction cycle. Administering acupuncture during
uterine lining.6 the pretreatment cycle (especially during the last week)
may help to improve follicular recruitment. Treatment
principles are the same as in IVF pretreatment with GnRH
Ovulation induction with LHRH (GnRH) antagonist protocol (see Table 9.4).
pulse pump system
For the induction of ovulation in patients with WHO grade
I ovulation disorders (see Chapter 8) the LHRH (GnRH)
Follicular (stimulation) phase
pulse pump system is beneficial.153 LHRH is injected intra- Acupuncture treatment during the follicular phase of the
venously via a mini pump at 90 min intervals.153 This ovulation induction cycle should ideally begin on men-
induces an increased production of FSH and LH and strual days 1–3 because by day 3 follicular recruitment is
improved pituitary-ovarian feedback. The starting dose is completed.6 Acupuncture treatment should then be
usually 2.5 mg34 to 5 mg153 per pulse, and the maximum repeated every 3–4 days until either the hCG trigger injec-
recommended dose is 20 mg.153 The pump is usually tion or the LH surge. Acupuncture principles and points are
attached on cycle day 1–3 and worn continuously until identical to IVF ovarian stimulation phase (Table 9.6).
ovulation.34
Ovarian response is monitored by serial ultrasound
scans and oestradiol levels. LH kits can be used to detect
Final egg maturation and ovulation trigger
the LH surge, which normally happens around 36 h before As in IVF, acupuncture administered shortly after the
ovulation. Intercourse should begin around the time of LH hCG trigger or LH surge may help with the final egg(s)
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maturation. The acupuncture treatment protocol is the IUI during a stimulated cycle
same as in IVF during this egg maturation stage (see In a stimulated IUI cycle, a woman usually injects herself
Table 9.8). subcutaneously with gonadotrophins, starting on day
3–5 of her menstrual cycle.155–158 In some cases CC or
Luteal phase other antioestrogens can be used.155 A GnRH antagonist
may also be administered to avoid a premature LH
Implantation is likely to take place 6–8 days after ovula-
surge.157
tion. Therefore administering acupuncture to women on
On cycle days 8–13, the response to stimulation is mon-
these days may help to increase the chances of implanta-
itored by serial blood tests to check the levels of LH and oes-
tion. Acupuncture during the luteal phase may also reduce
tradiol, and the extent of follicular growth is monitored by
the risk of miscarriages (as described in section ‘In vitro
transvaginal ultrasound.155,156,159
fertilization’). The treatment principles and points utilized
Sometimes, if a woman produces more than two follicles,
are identical to those outlined in Table 9.14 in
IUI may be cancelled or rescue IVF may be performed.154
section ’In vitro fertilization’.
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265
Acupuncture for IVF and Assisted Reproduction
Case study
Donor Egg IVF-acupuncture Treatment On day 11 Katie attended for a monitoring ultrasound
of the Recipient scan. Her endometrium was 9.62 mm thick and trilaminar in
Katie, aged 43, was undergoing donor egg IVF due to poor appearance. We decided that no further acupuncture
ovarian reserve. Her partner’s semen analysis was excellent, session was necessary because the endometrium was
and the donor was a 31-year-old relative. Katie’s menstrual already of good quality, and it was likely that it would increase
cycles had stopped for a year, but then restarted again a few in thickness a little more before the embryo transfer
months before IVF and were now 25–28 days long. procedure.
Egg Retrieval
Manifestations
Egg retrieval procedure in Katie’s donor went well and 13 eggs
® Menses: light, no pain
were recovered.
® Emotions: in the run up to IVF very tearful and feeling down In addition to oestrogen, Katie started progesterone
® Digestion: IBS, bloated, constipation, symptoms worse (Utrogestan vaginal capsules 2 200 mg twice a day) to be
before menstruation continued until 10 weeks’ gestation (if pregnant).
® Tension headaches
® Tongue: slightly purple
Fertilization
® Pulse: wiry on the left, weak on the right Disappointingly, only three eggs fertilized. Embryo transfer
was scheduled for 2 days later.
TCM Syndromes
Embryo Transfer
® Liver Qi Stagnation
The transfer went well. Two good-grade embryos were
® Spleen Qi Deficiency transferred. Two acupuncture sessions were administered,
® Kidney Jing [Essence] Deficiency approximately 2 h before and 2 h after the embryo transfer.
Paulus et al.84 embryo transfer acupuncture protocol
Pretreatment Phase
was used.
Katie’s menstrual cycle was supressed with a GnRH agonist
(buserelin), 500 mg to be injected subcutaneously daily starting Luteal Phase
with day 21 of the pretreatment cycle. Five days after the transfer (day 7 post egg retrieval) Katie had
Acupuncture: three acupuncture treatments were ‘cold like symptoms’. She felt breathless, tired, achy. She had
administered. Points used included LU7 + KID6, SP4 + P6, SP6, some abdominal ‘twinges’ that felt hot. Katie was beginning to
LIV3, SP3, ST29, KID3, YINTANG. feel very anxious and was experiencing panic attacks. Her pulse
was slightly rapid and very slightly slippery. Acupuncture
Follicular Phase prescription was LU7 + KID6, SP10, KID7, KID9, LIV3, LIV2,
Baseline scan confirmed that the lining was thin, and Katie was REN6, DU20, YINTANG.
prescribed oral oestrogen (Progynova®) to prime her Katie tested positive and the scan at 6 weeks’ gestation
endometrium. The dose was to be increased incrementally showed two gestation sacks. Katie continued to have
from 2 to 6 mg between days 1 and 10. acupuncture treatment throughout her pregnancy. Her
Two acupuncture treatments were administered on days 4 pregnancy was complicated by some vaginal bleeding and
and 9 of oestrogen priming. Acupuncture points included recurrent urinary infections, and she developed pre-eclampsia
REN4, ST29, ZIGONG, SP6, and HE7 (with a heat lamp placed later in pregnancy. Katie’s two healthy baby girls were
over the abdomen). delivered by c-section.
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Acupuncture for IVF and Assisted Reproduction
acupuncturists are unlikely to see many patients undergo- are necessary as the egg retrieval procedure is normally
ing this treatment. However, if a patient presents who is completed earlier in the cycle.
undergoing an IVM treatment, the following protocol
may be used to assist her.
Egg retrieval
Pretreatment (downregulation Orthodox medical protocol
or suppression) The egg retrieval procedure is similar to that used in IVF.
However, the aspiration technique, type of needle, and
Orthodox medical treatment aspiration pressure may be different when retrieving imma-
IVM protocols usually do not involve any pretreatment ture eggs in IVM.170
medication.
TCM protocol
Acupuncture The acupuncture egg retrieval protocol is the same as in
Acupuncture treatment is the same as for IVF pretreatment conventional IVF (see Table 9.10).
with short GnRH agonist protocol (see Table 9.4).
TCM protocol
Acupuncture treatment during the follicular phase of the
TCM protocol
IVM cycle is similar to that followed in conventional IVF Acupuncture embryo transfer protocols are the same as in
(see Table 9.6). The only difference is that fewer sessions conventional IVF (see Table 9.12).
268
Acupuncture during ART Chapter |9|
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its relationship with oocyte et al. Acupuncture lowers pregnancy the United States: an analysis of the
maturity and IVF outcome. Ann N Y rates when performed before and Society for Assisted Reproductive
Acad Sci 2001;943:64–7. after embryo transfer. Fertil Steril Technology database. Fertil Steril
119. Coulam CB, Goodman C, 2007;92:1870–9. 2013;100:392–5.
Rinehart JS. Colour doppler indices 128. ESHRE ART fact sheet. Available 139. Nargund G, Fauser BC,
of follicular blood flow as from: http://www.eshre.eu/ESHRE/ Macklon NS, et al. The ISMAAR
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in-vitro fertilization and embryo sheet/page.aspx/1061 (accessed 13 ovarian stimulation for IVF. Hum
transfer. Hum Reprod December 2012). Reprod 2007;22:2801–4.
1999;14:1979–82. 129. Robinson L, Gallos ID, Conner SJ, 140. Ghobara T, Vandekerckhove P.
120. Ozturk O, Bhattacharya S, et al. The effect of sperm DNA Cycle regimens for frozen-thawed
Saridogan E, et al. Role of fragmentation on miscarriage rates: embryo transfer. Cochrane Database
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predictor of ongoing pregnancy in meta-analysis. Hum Reprod 141. Al-Shawaf T, Yang D, Al-Magid Y,
an IVF – embryo transfer 2012;27:2908–17. et al. Infertility: ultrasonic
programme. Reprod Biomed 130. Zini A, Boman JM, Belzile E, et al. monitoring during replacement of
Online 2004;9:299–305. Sperm DNA damage is associated frozen/thawed embryos in natural
121. Bassil S, Wyns C, with an increased risk of pregnancy and hormone replacement cycles.
Toussaint-Demylle D, et al. The loss after IVF and ICSI: systematic Hum Reprod 1993;8:2068–74.
relationship between ovarian review and meta-analysis. Hum 142. Ashrafi M, Jahangiri N, Hassani F,
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stimulation in in-vitro fertilization. 131. Pritts EA, Atwood AK. Luteal phase outcome of frozen-thawed embryo
Hum Reprod 1997;12:1240–5. support in infertility treatment: a transfer cycle. Taiwan J Obstet
122. Macklon NS, Stouffer RL, meta-analysis of the randomized Gynecol 2011;50:159–64.
Giudice LC, et al. The science trials. Hum Reprod 143. Weissman A, Levin D, Ravhon A,
behind 25 years of ovarian 2002;17:2287–99. et al. What is the preferred method for
stimulation for in vitro fertilization. 132. Zarutskie PW, Phillips JA. timing natural cycle frozen-thawed
Endocr Rev 2006;27:170–207. A meta-analysis of the route of embryo transfer? Reprod Biomed
123. Stener-Victorin E, Waldenström U, administration of luteal phase Online 2009;19:66–71.
Nilsson L, et al. A prospective support in assisted reproductive 144. Groenewoud ER, Cantineau AE,
randomized study of electro- technology: vaginal versus Kollen BJ, et al. What is the optimal
acupuncture versus alfentanil as intramuscular progesterone. Fertil means of preparing the
anaesthesia during oocyte Steril 2009;92:163–9. endometrium in frozen-thawed
aspiration in in-vitro fertilization. 133. Var T, Tonguc EA, Doğanay M, et al. embryo transfer cycles?
Hum Reprod 1999;14:2480–4. A comparison of the effects of three A systematic review and
124. Nikas G, Makrigiannakis A, different luteal phase support meta-analysis. Hum Reprod Update
Hovatta O, et al. Surface protocols on in vitro fertilization 2013;19:458–70.
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aspects. Ann N Y Acad Sci 134. van der Linden M, Buckingham K, cycles for endometrial preparation
2000;900:316–24. Farquhar C, et al. Luteal phase prior to frozen-thawed embryo
125. Chien LW, Lee WS, Au HK, et al. support for assisted reproduction transfer. Reprod Biomed Online
Assessment of changes in utero- cycles. Cochrane Database Syst Rev 2006;13:321–5.
ovarian arterial impedance during 2011;(10):CD009154. 146. Nawroth F, Ludwig M. What is the
the peri-implantation period by 135. Khorram NM. Adjuvant ’ideal’ duration of progesterone
doppler sonography in women acupuncture reduces first trimester supplementation before the transfer
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Ultrasound Obstet Gynecol Obstet Gynecol 2012;02:283–6. in estrogen/progesterone
2004;23:496–500. 136. Ke SX. Treating infertility in replacement protocols? Hum
126. Ivanovski M, Damcevski N, Traditional Chinese medicine. Eur J Reprod 2005;20:1127–34.
Radevska B, et al. Assessment of Orient Med 2008;6:10–1. 147. Glujovsky D, Pesce R, Fiszbajn G,
uterine artery and arcuate artery 137. Lawler CC, Budrys NM, Rodgers AK, et al. Endometrial preparation for
blood flow by transvaginal color et al. Serum beta human chorionic women undergoing embryo
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embryos derived from donor 155. Kosterman M. Intrauterine 163. Jarrett LS. The Liver. In: The clinical
oocytes. Cochrane Database Syst insemination. In: de Haan N, practice of Chinese medicine.
Rev 2010;(1):CD006359. Spelt M, Gobel R, editors. Stockbridge, Mass: Spirit Path Press;
148. Amir W, Micha B, Ariel H, et al. Reproductive medicine: a textbook 2003. p. 549–70 [chapter 31].
Predicting factors for endometrial for paramedics. Amsterdam: 164. Jarrett LS. Kidney. In: The clinical
thickness during treatment Elsevier Gezondheidszorg; 2010. practice of Chinese medicine.
with assisted reproductive p. 101–4 [chapter 7]. Stockbridge, Mass: Spirit Path Press;
technology. Fertil Steril 156. Tonguc E, Var T, Onalan G, et al. 2003. p. 427–59 [chapter 27].
2007;87:799–804. Comparison of the effectiveness of 165. Lu HC. Section three: Spiritual pivot
149. Zhang X, Chen CH, Confino E, et al. single versus double intrauterine [Ling Shu]. Verbal questions. In: A
Increased endometrial thickness is insemination with three different complete translation of the Yellow
associated with improved treatment timing regimens. Fertil Steril Emperor’s classics of internal
outcome for selected patients 2010;94:1267–70. medicine and the difficult classic
undergoing in vitro 157. Matorras R, Ramón O, Expósito A, (Nei-Jing and Nan-Jing).
fertilization-embryo transfer. Fertil et al. Gn-RH antagonists in Vancouver: International College of
Steril 2005;83:336–40. intrauterine insemination: the Traditional Chinese Medicine;
150. So EW, Ng EH, Wong YY, et al. weekend-free protocol. J Assist 2004. p. 481–7 [chapter 28].
Acupuncture for frozen-thawed Reprod Genet 2006;23:51–4. 166. Shenfield F, Pennings G, Cohen J,
embryo transfer cycles: a 158. Yulian YZ. Impact of semen et al. ESHRE task force on ethics and
double-blind randomized characteristics on the success law 10: surrogacy. Hum Reprod
controlled trial. Reprod Biomed of intrauterine insemination. 2005;20:2705–7.
Online 2010;20:814–21. J Assist Reprod Genet 167. Rowell P, Braude P. Assisted
151. Gysler M, March CM, Mishell DR, 2004;21:143–8. conception. I – General principles.
et al. A decade’s experience with an 159. Zadehmodarres S, Oladi B, Saeedi S, BMJ 2003;327:799–801.
individualized clomiphene et al. Intrauterine insemination 168. Friel KS, Penzias AS. Intratubal
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Chapter | 10 |
Clinical issues during ART
It is often assumed that the only hurdle to overcome during blows for couples because they feel cheated of their chance
Assisted Reproductive Technology (ART) treatment is of succeeding with IVF.
whether the treatment results in a pregnancy. However, The next potential stumbling block is the embryo trans-
in reality, various problems can arise before a pregnancy fer procedure. Most procedures are carried out without any
test day, as the following examples illustrate. complications. However, in a few cases, things go wrong.
During the downregulation phase when medication is The next few sections will discuss in more detail what
used to block the release of Follicle Stimulating Hormone problems may arise during each stage of the IVF cycle
(FSH) and Luteinizing Hormone (LH) in order to suppress and what solutions are available to manage the resulting
follicular growth, women may not respond as expected issues. Figure 10.1 summarizes the clinical complications
physiologically, and they may fail to downregulate. This that can arise at different stages of a typical IVF cycle.
problem is relatively easily overcome, and most clinics will
extend the period for downregulation until the woman has
appropriately downregulated. Issues may develop during
the stimulation phase. For example, the follicles may not POOR FOLLICULAR DEVELOPMENT
grow sufficiently well, there may be too few follicles, or
the endometrium may not develop adequately. Sometimes, Poor ovarian response is a situation where too few follicles
at the egg retrieval stage, not all follicles will contain an egg, develop during the ovarian stimulation phase.
and not all of the eggs that are retrieved will be mature; in As discussed in Chapter 9, follicular growth during
some cases, no eggs will be retrieved. On some rare occa- the stimulation phase is monitored by regular transvaginal
sions, men may fail to produce a semen sample on the ultrasound scans, which usually start on day 5–7 of the
day of egg retrieval or may produce a very poor sample. ovarian stimulation phase and are repeated every 1–3 days.
The In Vitro Fertilization (IVF) fertilization rate (that is, Average follicular size is determined after two-plane measure-
the percentage of eggs expected to be fertilized in the ments of individual follicles. Sizes are plotted on a chart.
laboratory) is about 60–70%.1 However, some couples will A review by Baerwald et al. established that, during ovar-
consistently have lower than average fertilization rates. In ian stimulation cycles, ovulatory follicles’ mean growth rate
exceptional cases, none of the eggs will be fertilized. This is 1.64 0.02 mm/day.2 Interestingly, anovulatory follicles
can occasionally happen even in couples who have a good grow at a slightly faster rate of 1.85 0.04 mm/day2 as
number of retrieved eggs. compared to a natural cycle (1.48 0.10 mm for ovulatory
The next stage at which problems can arise is during and 1.41 0.06 mm for anovulatory follicles).2 Basically,
embryo development. Embryos develop for up to 6 days this means that it is undesirable for follicles to develop
following egg retrieval. Not all embryos are expected to too quickly or too slowly.
continue developing. But, in some cases, the embryo In some individuals, only one or two follicles will
demise rate is higher than the expected frequency. Occa- develop. In these cases, the treatment cycle may be can-
sionally, no embryos survive to the embryo transfer stage. celled (except in natural or mild IVF, where the aim is to
This is one of the most devastating psycho-emotional only retrieve one or two eggs).
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Clinical issues during ART Chapter | 10 |
in poor responders compared to luteal pretreatment with lower abdominal area (for example, a moxa box or a
GnRH agonist or oral contraceptive pills.18 heat lamp)
• LU7 + KID6, SP4 + P6, REN8, REN12, REN14, REN15,
KID13, ST27, and ZIGONG
Higher stimulation dose
• Acupuncture treatment frequency may need to be
The standard dose of stimulation is between 150 and increased to every 2–3 days
300 IU of Follicle Stimulating Hormone (FSH) per day.18
In patients at risk of poor response, the starting dose of
FSH may need to be between 300 and 450 IU/day.18
Combination of very large and small follicles
However, doses higher than this are ineffective.7,18 A higher In addition to the syndromes listed above, Liver Qi Stagna-
starting dose of medication is necessary in order to maxi- tion may be involved. Additional points include LIV3,
mize the amount of follicular recruitment, which happens LIV2, LI4, ST29, KID13, and SP10.
during the late luteal and early follicular phases.18
Acupuncture: Preventative treatment
Minimal stimulation dose or natural IVF Other long-term approaches to managing patients with a
A criticism of increasing the dose of stimulation medication history of poor response to stimulation are described in
is that ovarian response is largely determined by the num- Chapter 9 in the sections on ovarian stimulation.
ber of antral follicles.7 If there are not many follicles to start
with, a higher dose of medication will not make any differ-
ence. Therefore, minimal stimulation or natural IVF IMMATURE OR NO EGGS
should be considered in patients who have a history of
poor response because these patients are likely to produce
Overview
a low number of eggs, irrespective of the dose of the
stimulation medication.18 The previous section discussed poor follicular develop-
ment, where a woman does not respond well to stimula-
tion medication and there is inadequate development of
Weight loss only a few follicles. This section will discuss a situation
Overweight women undergoing ART require more gonad- where the follicles develop normally but yield few or no
otropin stimulation, and they have poorer response rates eggs (referred to as Empty Follicle Syndrome or EFS) or
and produce fewer eggs.19 Therefore, women who are over- yield immature eggs. This event is usually unexpected
weight or obese should be encouraged to lose weight (see and can potentially lead to the cancellation of a treatment
Chapter 7). cycle. EFS results in significant psycho-emotional effects
and financial implications for a couple.
As discussed in Chapter 9, the Human Chorionic Gonad-
Acupuncture: Rescue treatment otrophin (hCG) trigger medication is usually injected 36 h
Follicles develop too quickly before the retrieval of the eggs. It initiates the final egg mat-
uration process. It is normal for a small number of follicles
If follicles develop too quickly, Full or Empty Heat is usu- to not have an egg within them or to produce an immature
ally implicated. Empty Heat may arise as a result of under- egg. However, the majority of follicles should produce a
lying Kidney Yin Deficiency and/or Liver Yin and/or Blood mature egg. Research shows that the chances of a live birth
Deficiency. Full Heat is usually from Liver Qi Stagnation. In are greater if 621 to at least 1322 mature eggs are retrieved.
the authors’ experience, the following points are helpful:
• Clear Heat, Regulate the Chong and Ren Mai
(Penetrating and Conception Vessels), Nourish Blood: Empty follicle syndrome
KID2, LIV2, LIV3, REN3, P7, KID8, LI11, ST36 EFS can be ‘genuine’ or ‘false’. In genuine EFS, hCH level
on the day of egg retrieval is >40 IU/L, whereas, in false
Follicles develop too slowly EFS, hCH level is <40 IU/L, either because the patient
did not administer the trigger hCG correctly, because the
When follicles grow too slowly, this problem may be due to patient administered a faulty batch of hCG, or because of
different combinations of underlying deficiencies of Qi, issues with the bioavailability of hCG.23 False EFS is more
Blood, Yin, and/or Jing (Essence). In the authors’ experi- common compared to genuine EFS (0.072% and 0.016%,
ence, the following points and treatments may be helpful: respectively).24 Borderline EFS is where some eggs are
• Tonify Qi and facilitate Blood flow to the Uterus: ginger retrieved but not from all follicles. In the authors’ experi-
with moxa cones on the ovary area20 or heat on the ence, this situation is more common in patients who,
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Acupuncture for IVF and Assisted Reproduction
having experienced EFS, then decide to seek acupuncture to different policies on when patients are ready for the trigger
prevent EFS in subsequent IVF treatment cycles. injection. For example, some clinics will do the trigger
Some studies show that the occurrence of genuine EFS is when three or more follicles are 16 mm, others when
a prognostic indicator of a poor IVF outcome in subsequent the follicles are 18 mm in diameter. In some clinics,
IVF cycles25,26 and is associated with reduced ovarian the decision is dictated by practical logistical aspects, for
reserve.27 example, triggering a day sooner or a day later in order
to avoid a weekend egg retrieval.
The research evidence on this is very mixed. Some studies
Follicular flushing show that the size of the follicles on the day of egg retrieval
Sometimes the follicle is classed as empty, but, in reality, makes no difference to the number of eggs retrieved
the egg is ‘stuck’ inside the follicle, giving the impression while other studies show that delaying the time of egg
that the follicle is empty. This is referred to as egg (oocyte) retrieval results in more eggs. The following studies illus-
retention. A 2012 systematic review claims that potentially trate the difficulty that presently exists in making any con-
about 50% of eggs may be retained inside the follicles after vincing evidence-based recommendations about when
standard follicular aspiration, especially in patients with hCG should be administered, the quality of eggs retrieved,
poor response to ovarian stimulation.28 and subsequent live birth rates.
The technique of follicular flushing is believed to help • A study of 423 patients undergoing IVF found that
minimize the risk of retained eggs. In a standard egg triggering when three or more follicles were 17 mm
retrieval procedure, a single lumen needle is used for follic- in diameter compared to triggering 2 days later resulted
ular aspiration. With follicular flushing, a double-lumen in no difference in egg quality although there was a
needle is used to retrieve eggs. With this technique, as the significantly higher ongoing pregnancy rate in the
follicular fluid is extracted with one channel in the needle, group who triggered early.34
saline fluid is instilled into the follicle via another channel. • Another study analysed 1577 IVF cycles and found
This is thought to help flush out the egg, which might not no significant differences in the number of mature eggs
be picked up with standard aspiration. retrieved, the number of embryos, and the live
Currently, the research evidence is equivocal for the use birth rates from four different follicular size groups
of this technique. For example, a systematic review and (two or more lead follicles <18 mm, 18–18.9 mm,
meta-analysis of five trials and 428 patients evaluated if 19–19.9 mm, and 20 mm). However, there was a
follicular flushing can improve the outcomes of ART. The nonsignificant decline in live birth rates as lead follicle
review authors concluded that while there is no evidence sizes increased.35
that routine use of follicular flushing is beneficial, the • In one study, 125 women undergoing IVF/ICSI
technique may be of benefit in patients with a history of (Intracytoplasmic Sperm Injection) were randomized
poor response to ovarian stimulation and in natural or into three groups: (A) trigger administered when three
mild IVF cycles, where even a marginal improvement in or more follicles were 17 mm in diameter, (B) 1 day
the oocyte retrieval rate could make a difference to the later, (C) 2 days later. There were no statistically
ART outcome.28 significant differences among the three groups in the
However, another systematic review and meta-analysis number of eggs retrieved. However, pregnancies and
of six randomized trials and 518 patients found that follic- live birth rates were nonsignificantly higher in groups B
ular flushing did not improve ART rates in normal respond- and C (A ¼ 30.8%, B ¼ 54.1%, C ¼ 38.7%; A ¼ 17.9%,
ing patients or in poor responders.29 B ¼ 27.0%, C ¼ 25.8%, respectively). The authors
therefore suggested that egg retrieval can be scheduled
to suit the clinic, for example, to avoid weekend
Higher dose or different ‘trigger’ medication procedures.36
Genuine EFS can be managed in subsequent cycles by using • In another study of 120 women undergoing IVF or
a different trigger medication instead of urinary hCG, for ICSI, significantly more mature eggs were retrieved
example, recombinant hCG, recombinant Luteinizing from the early hCG administration group (three or
Hormone, or GnRH agonist in an antagonist cycle.30 more follicles 16 mm in diameter) compared to the
Adding FSH at the time of hCG trigger increases the likeli- late (1 day later) hCG administration group. However,
hood of egg recovery.31,32 no significant differences were found in pregnancy
The other option is to increase the dose of hCG trigger, rates or ongoing pregnancy rates.37
usually from 5000 to 10,000 IU. • A large study of 1642 IVF antagonist cycles analysed if
delaying egg retrieval by 1 day or bringing it forward by
1 day from the ideal day negatively affects the outcome.
Timing of hCG trigger While more eggs were retrieved in the group where the
Follicles as small as 10 mm in diameter can contain a egg retrieval was delayed by 1 day, no significant
mature egg capable of being fertilized.33 ART clinics have difference in live birth rates was detected.38
278
Clinical issues during ART Chapter | 10 |
• Another study, which analysed 235 cycles and 2934 The role of the acupuncturist
retrieved eggs, found that the odds of retrieving a
mature egg from follicles 16–18 mm in diameter As already discussed in Chapter 2, acupuncture may
compared to >18 mm were 37% lower and declined improve the quality of the follicles and eggs within them
progressively with each smaller size.33 by improving the blood flow to the ovary.46
• In a large retrospective analysis of 1109 IVF cycles and Regular and frequent treatment during the stimulation
606 patients, egg retrieval rate was highest (at 83.5%) phase may help with follicular development. In one study
from follicles 16–18 mm in diameter on the day of egg of acupuncture in mice undergoing ovarian stimulation, it
retrieval and lowest from follicles 12 mm or >24 mm was found that acupuncture on SP6 three times during the
in diameter.39 stimulation period resulted in an almost twofold increase
in the number of mature eggs in the acupuncture group
Although per cycle pregnancy rates seem to be similar in
compared with the control group, where some of the eggs
different follicle groups, there is a weak trend of evidence
were retained in unruptured follicles. SP6 was chosen
that cumulative pregnancy rates may be higher when
because of its connection with Kidneys, Liver, and Spleen
hCG is delayed by a day or two because slightly more eggs
Zangfu organs and their function of regulating Qi and
are retrieved.40
Blood. The authors hypothesized that acupuncture
enhances follicular recruitment, inhibits follicular atresia,
and enhances action of hCG in promoting ovulation.47
> 36 h between the trigger injection In our experience, if on the day of the trigger injection
and egg retrieval there are several smaller to medium-size follicles (10–
15 mm in diameter), acupuncture treatment on the day
The time interval between the trigger injection and egg before egg retrieval aids hCG’s function of final follicular
retrieval has historically been set at around 36 h. However, maturation and seems to increase the number of mature
this has not been extensively studied. One study found that eggs retrieved from these follicles. The following acupunc-
trigger injection can be done any time between 34 and 38 h ture point prescription works particularly well: SP4 + P6,
before egg retrieval without any detrimental effects.41 SP6, ST36, SP10, LIV8, KID3 plus abdominal points
Another study also found no difference in egg yield in ST29, ZIGONG, and REN4. Moxa or a heat lamp on
<36.5 and 36.5 h intervals although a longer time inter- abdominal points is indicated. Acupuncture treatment on
val resulted in better implantation, clinical pregnancy rates, this day has also been recommended by other authors.48
and live birth rates in women more than 40 years of age.42 In the authors’ experience, the following Traditional Chi-
A longer time interval between trigger injection and egg nese Medicine (TCM) syndromes can cause a low number
retrieval may be useful in patients with a previous history of eggs and/or immature eggs:
of a large number of immature eggs.
• Pre/Post-Natal Jing (Essence) Deficiency
• Yin and/or Yang Deficiency
• Blood Deficiency
Rescue hCG • Qi Deficiency
In patients with false EFS (where hCG is <40 IU/L), hCG • Qi Stagnation
can be readministered, and egg retrieval can be rescheduled • Phlegm-Damp
36 h later.43 • Blood-Stasis
Acupuncture treatment of these syndromes is discussed in
Chapter 5.
Donor eggs
In cases of recurrent genuine EFS, egg donation may be the
only option available to these patients. SUBOPTIMAL ENDOMETRIAL LINING
Overview
Immature eggs
In order for the embryo to implant, the endometrial lining
A rate of 25% of immature eggs is not associated with needs to be of appropriate thickness and receptive to the
adverse ART outcomes.44 If the eggs are immature, they embryo. The lining also needs to be trilaminar (triple layer)
can be left to mature in the laboratory in a procedure called in appearance. Chapter 2 described in detail how the endo-
In Vitro Maturation or IVM (discussed in more detail in metrial lining develops.
Chapter 6). IVM may be a feasible option for patients The endometrial lining during the late follicular phase
who have a history of genuine EFS or in cases where the needs to be at least 6–8 mm thick,49 and it can be up to
retrieved eggs are not mature.45 16–17 mm thick or, in a few cases, even thicker.50,51
279
Acupuncture for IVF and Assisted Reproduction
Implantation and clinical and ongoing pregnancy rates are to the Pulsatile Index (PI) of the uterine arteries (that is, the
significantly increased if the endometrial lining is thicker resistance of the blood flow to the uterus). In one study,
than 9–10 mm.50,52,53 Clinical pregnancies and live birth electro-acupuncture significantly reduced PI. Acupuncture
rates increase linearly with increasing thickness of the was administered four times, twice a week from day 2 of
endometrium, even after adjusting for age and embryo ovarian stimulation until the day before egg retrieval. Acu-
quality.50,51 There does not appear to be an upper limit puncture points needled bilaterally were: LIV3, SP6, ST28,
to the endometrial thickness, with a lining >14 mm thick ZIGONG, REN6, and REN4.65
not associated with adverse outcomes.54,55 In another study, eight sessions of electro-acupuncture
Some studies, however, have not found any correlation were administered twice a week for 4 weeks. PI was signif-
between the thickness of the endometrial lining and icantly reduced after the eighth session and 10–14 days
pregnancy rates.56,57 later. Acupuncture points used were bilateral BL23 and
All fertility clinics have different cutoff points for what BL28 (100 Hz, pulses of 0.5 ms duration) plus bilateral
they consider to be adequate endometrial thickness. It is SP6 and BL57 (2 Hz, pulses of 0.5 ms duration).66
not uncommon for clinics to recommend freezing all Other studies have investigated if acupuncture treatment
embryos if the lining is <6–7 mm thick. increases endometrial thickness. In a pilot study combining
acupuncture and sildenafil (vaginal Viagra) in four patients
who previously failed to achieve a uterine lining
Causes and therapeutic options of 8 mm, five sessions of acupuncture treatment during
Age may affect the endometrial lining, with older women the IVF cycle resulted in all four patients developing a lining
having thinner linings.55,58,59 This may be because endo- of >9 mm (even in those who had received Viagra in pre-
metrial development depends on good oestrogen levels.59 vious IVF cycles without success).67
A repeatedly thin endometrium (<7 mm) might be In another pilot study evaluating 14 women in the acu-
caused by previous surgical curettage, even if, subsequently, puncture group and 14 women in a control group, no
no signs of adhesions are found.60 Therefore, in cases of changes to the endometrium were detected between the
repeatedly thin endometrium, advanced uterine investiga- two groups. However, in this study, only one acupuncture
tions should be undertaken. In cases where adhesions are treatment was performed during the stimulation phase
found, they should be surgically removed. (day 9), followed by acupuncture treatment before and
Therapeutic options include: after the embryo transfer.68 We would argue that one acu-
puncture treatment session during the stimulation phase is
• Stimulation with a high dose of oestrogens or vaginal not enough to achieve the desired therapeutic effect.
oestrogen pills49
A recently published randomized controlled trial
• Medication that may increase the blood flow to the
showed that patients who received acupuncture treatment
endometrium.49 For example, aspirin61 and/or low-
during the stimulation phase of an IVF cycle had signifi-
molecular weight heparin, a high dose
cantly thicker endometrial linings compared to the control
(400–500 IU/day) of vitamin E from day 3 to hCG
and sham groups (10.3 mm vs. 8.7 mm vs. 8.5 mm, respec-
trigger,62 pentoxifylline,63 sildenafil (vaginal Viagra)64
tively). Acupuncture treatment was done on days 1 and 7 of
• Investigative and therapeutic uterine evaluation
ovarian stimulation, on the day before the egg retrieval, and
• Surrogacy if other treatments fail49
on the day after the embryo transfer. The acupuncture
point prescription was as follows: unilateral moxibustion
Lifestyle advice was administered for 5 min on BL18, BL22, BL23, BL52,
REN3, REN4, REN5, REN7, DU4, followed by unilateral
TCM advocates applying heat to the surface of the abdo- acupuncture on P6, KID3, KID6, KID7, KID10, LIV3,
men (for example, a hot wheat pack), which may help to SP4, SP6, SP10, ST40, LU7, and bilateral ZIGONG. De qi
move stagnant Blood in the Uterus. Moderate exercise or was obtained, and needles were retained for 20 min.69
physical activity may also help with blood circulation.
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fertilization.73 If the pronuclei cannot be seen, it could Some clinics offer ICSI to all couples, including those
mean that either the eggs failed to fertilize or the fertiliza- with nonmale factor subfertility. However, the routine
tion is delayed. use of ICSI in couples with nonmale factor subfertility is
About 60–70% of retrieved eggs normally are fertilized, questionable. For example, one study assessed the routine
and the rates are similar in IVF and ICSI.1 Fertilization rates use of ICSI in nonmale factor cases. The fertilization failure
strongly predict the outcome of the ART cycle.74 Total Fer- rate was significantly higher in the IVF group than in the
tilization Failure (TFF) is when none of the available eggs ICSI group (5% and 2%, respectively), and implantation
fertilize. TFF happens in 5–16% of IVF cycles.75–78 In cases rates were significantly higher in the IVF group than in
where TFF occurs, there is a 29% chance of it recurring.78 the ICSI group (30% vs. 22%). Clinical pregnancy rates,
There is an inverse relationship between eggs retrieved however, were not significantly different.75
and TFF. TFF becomes much less likely the more eggs are The skill of the embryologist can also influence ICSI suc-
retrieved. When TFF does happen, it is unlikely to be caused cess rates.74
by a random event. A recent review found that most cases
of failed fertilization can be broadly attributed to the
following causes:1 Other causes of fertilization failure
• Insufficient number or poor-quality eggs Women with hypothyroidism have a lower fertilization
• Low number or poor-quality sperm rate than euthyroid women.86–89 A meta-analysis found
• Defective culture medium that treatment with Levothyroxine (LT4) improves the fer-
tilization rates in these women.86
A lower fertilization rate may also be related to the size of
Fertilization failure in IVF the follicles. A study of 412 IVF/ICSI cycles and 340 women
Sperm factor is implicated in the majority of cases of failed that compared different-sized follicles’ fertilization compe-
fertilization with IVF. Interestingly, 52% of couples with tence found that medium-sized follicles (16–23 mm on the
TFF have normal pre-IVF semen parameters.79 However, day of aspiration) produced significantly better fertilization
sperm parameters on the day of insemination appear to rates compared to small (<16 mm) and large (>23 mm)
be strongly correlated with fertilization rates.1 The main follicles.90 Another study that analysed 235 cycles and
issue lies with failure by sperm to penetrate the zona pellu- 2934 retrieved eggs found that eggs retrieved from follicles
cida (outer shell of the egg).1 Tests are available to assess 16–18 mm in diameter were 28% less likely to result in fer-
sperm–zona pellucida binding. However, in most cases tilization compared to eggs from follicles >18 mm.33 So, in
where there is a history of failed fertilization, the ICSI tech- cases with fertilization issues, it is important to ensure that
nique should be used in any future treatment cycles. In egg retrieval is carefully timed.
ICSI, one sperm is injected inside the egg, thereby bypass- Table 10.1 summarizes common causes of fertilization
ing the need for sperm to penetrate the zona pellucida (see failure and therapeutic options.
Chapter 6 for more details on ICSI). ICSI outcomes are
independent of semen quality and quantity.1
The egg is less frequently implicated in TFF in IVF. Cases
The role of the acupuncturist
that do happen are usually because there are too few eggs or When patients suffer failed fertilization, they are devas-
the eggs are abnormal, usually related to advanced mater- tated. As acupuncturists, we can support them by providing
nal age.1 In cases where fewer than three eggs are retrieved, them with information (especially if the provision of infor-
TFF is common.80 Animal studies show that omega-3 mation is time critical) and by helping them to deal with
supplementation may improve egg quality.81 the emotional fallout.
In cases where the preparatory phase of acupuncture
treatment was not long enough or where TCM pathology
Fertilization failure in ICSI was not adequately addressed in both partners, it may be
Up to 50% of cases of failed fertilization following ICSI are appropriate to suggest a longer course of preparatory
attributed to DNA damage of the spermatozoon and the acupuncture before undergoing further IVF treatment. An
egg (in equal proportion), and about 40% of cases are assessment and treatment with acupuncture of male part-
caused by failure of egg activation. TFF in ICSI cycles can ners is essential in most cases with fertilization issues.
also be caused by a low number of retrieved eggs.1 In the authors’ experience, the following syndromes may
Antioxidant supplementation82 and shorter abstinence cause fertilization issues:
time before ejaculation83 have been reported to improve • Kidney Jing (Essence) Deficiency
sperm DNA. • Qi Deficiency
If after ICSI, there has been a failure of fertilization, then • Blood Deficiency91
assisted egg activation (usually chemical or electrical) can • Yin and/or Yang Deficiency
be used to try and achieve fertilization.84,85 • Shen (Spirit) affected
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Clinical issues during ART Chapter | 10 |
Table 10.1 Summary of fertilization methods, causes of failure, and treatment options available
The section ‘Embryo Grading’ in Chapter 6 provides Causes of poor embryo development
detailed information about normal embryonic develop-
ment. This section will briefly review the causes of poor Maternal influences
embryo development and, where available, will provide The majority of embryos fail to develop because of faulty
details of therapeutic options. DNA. Embryo development depends on the quality of
283
Acupuncture for IVF and Assisted Reproduction
Paternal influences
Embryo development, especially embryo cell division, also
depends on the quality of the sperm.92 Paternal genes are DIFFICULT EMBRYO TRANSFER
switched on at the four-cell stage, and, therefore, sperm
DNA may be implicated if embryos stop developing at this
time or soon afterward.96 A meta-analysis found very little
What can go wrong and the
consistent evidence that sperm DNA damage influences consequences
embryo quality although the authors acknowledge that Chapter 9 provides detailed information about what hap-
sperm DNA damage may be a more significant factor in pens during the embryo transfer procedure. Most embryo
ICSI cycles.97 transfers go smoothly and take only few minutes. However,
in some cases, there may be complications, referred to as
difficult transfers. The most common embryo transfer com-
Other factors plications are:
The quality of culture medium used in the laboratory, the skill • Painful transfer
of the embryologist, and the environment in the laboratory • Technically difficult transfer for the clinician (difficulty
are other factors that influence embryo development. inserting the speculum and/or catheter)
• Issues with embryo(s) discharge from the catheter into
the uterus
Difficult transfers are associated with lower success
INTERESTING FACTS
rates102–104 possibly because they stimulate uterine contrac-
EFFECT OF SEASONS ON EMBRYO QUALITY tions105,106 or because the embryos get damaged in the pro-
cess of transfer. Successful cycles have shorter times between
In a retrospective study, 1072 consecutive IVF cycles were the embryo being loaded into a catheter and its discharge
categorized according to the seasons, based on the day on into the uterus, compared to unsuccessful cycles. Intervals
which women started their medication. There was a of >120 s are associated with poor prognosis.107 However,
significant difference in embryo quality (expressed as too fast an ejection of the embryos can also damage them.108
percentage) depending on the season, with the best quality
embryos developing in spring:98
® Winter (December–February): 38.2% Therapeutic options
® Spring (March–May): 54.2%
Several options are available to patients with a history of
® Summer (June–August): 48.2%
difficult or painful embryo transfer:
284
Clinical issues during ART Chapter | 10 |
• Sedation or general anaesthesia may be offered for Patients who have previously experienced difficult trans-
future embryo transfers. fers prior to starting acupuncture treatment often comment
• Holding the cervix by volsellum should be avoided how much easier their transfer was after acupuncture. Most
except in few rare cases.106 acupuncture embryo transfer protocols outlined in
• A dummy (trial) embryo transfer may be performed to Chapter 9 include strong calming points, and these will
assess the uterine cavity.105 help the patient to feel more relaxed for the transfer.
• Cervical mucus should be removed with saline liquid SP6 is known for its effect on the cervix. Applying
because mucus may block the tip of the catheter, thus a semipermanent needle to SP6 before the transfer and
blocking the embryos’ passage or causing them to stick removing it after the transfer can help to soften the cervix.
to the mucus and therefore be extracted with the Alternatively, the ear cervix point may also be used. The
catheter when it is removed from the uterus.106 point LI4 can be used for managing the pain of those
• Different catheters may be used.105 patients who have previously experienced painful embryo
• Ultrasound-guided transfer may be used, if it was not transfer.
used previously.109 Immediately after a difficult transfer, it is important to
• Transfer may be performed by a more experienced use the points that decrease uterine contractions. Animal
clinician.110 studies show that LI4115 and SP6116 can reduce uterine
• Cervical dilation prior to gonadotrophin stimulation motility. Interestingly, both these points are commonly
may help to ‘stretch’ the cervix.111,112 used in postembryo transfer acupuncture protocols
• In extremely severe cases, alternative methods of although a study on human participants using LI4 and
transfer can be used. For example, transmyometrial105 SP6 in combination with other points did not find any
or Zygote Intrafallopian Transfer.113 reduction in uterine contractions.117 This may be because
• Following the transfer, if embryos are found inside the of a combination of points otherwise used in this study
catheter, they need to be retransferred immediately. or, alternatively, because LI4 and SP6 are not effective at
This way the pregnancy is not compromised.114 reducing uterine contractions in humans.
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1997;68:171–3. In vitro fertilization pregnancy Fertil Steril 2000;74:476–81.
288
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99. Hicks A, Hicks J, Mole P. The 105. Mains L, Van Voorhis BJ. stenosis who are participating in an
use of acupuncture points. In: Optimizing the technique of in vitro fertilization-embryo
Five element constitutional embryo transfer. Fertil Steril transfer program? The Bourn Hall
acupuncture. Edinburgh: Churchill 2010;94:785–90. experience. Fertil Steril
Livingstone; 2005. p. 261–78. 106. Mansour RT, Aboulghar MA. 1999;72:610–2.
[chapter 36]. Optimizing the embryo transfer 112. Noyes N, Licciardi F, Grifo J, et al.
100. So EW, Ng EH, Wong YY, et al. technique. Hum Reprod In vitro fertilization outcome
A randomized double blind 2002;17:1149–53. relative to embryo transfer
comparison of real and placebo 107. Matorras R, Mendoza R, Expósito A, difficulty: a novel approach to the
acupuncture in IVF treatment. Hum et al. Influence of the time interval forbidding cervix. Fertil Steril
Reprod 2009;24:341–8. between embryo catheter loading 1999;72:261–5.
101. Magarelli PC, Cridennda DK, and discharging on the success of 113. Das M, Holzer HE. Recurrent
Cohen M. Changes in serum IVF. Hum Reprod implantation failure: gamete and
cortisol and prolactin associated 2004;19:2027–30. embryo factors. Fertil Steril
with acupuncture during controlled 108. Grygoruk C, Sieczynski P, 2012;97:1021–7.
ovarian hyperstimulation in Modlinski JA, et al. Influence of 114. Nabi A, Awonuga A, Birch H, et al.
women undergoing in vitro embryo transfer on blastocyst Multiple attempts at embryo
fertilization-embryo transfer viability. Fertil Steril transfer: does this affect
treatment. Fertil Steril 2011;95:1458–61. in-vitro fertilization treatment
2009;92:1870–9. 109. Abou-Setta AM, Mansour RT, Al- outcome? Hum Reprod
102. Tomás C, Tikkinen K, Inany HG, et al. Among women 1997;12:1188–90.
Tuomivaara L, et al. The degree of undergoing embryo transfer, is the 115. Kim J-S, Shin KH, Na CS. Effect of
difficulty of embryo transfer is an probability of pregnancy and live acupuncture treatment on
independent factor for predicting birth improved with ultrasound uterine motility and
pregnancy. Hum Reprod guidance over clinical touch alone? cyclooxygenase-2 expression
2002;17:2632–5. A systemic review and meta-analysis in pregnant rats. Gynecol
103. Spitzer D, Haidbauer R, Corn C, of prospective randomized trials. Obstet Invest 2000;50:225–30.
et al. Effects of embryo transfer Fertil Steril 2007;88:333–41. 116. Kim JS, Na CS, Hwang WJ, et al.
quality on pregnancy and live birth 110. De Placido G, Wilding M, Stina I, Immunohistochemical
delivery rates. J Assist Reprod Genet et al. The effect of ease of transfer localization of cyclooxygenase-2 in
2012;29:131–5. and type of catheter used on pregnant rat uterus by Sp-6
104. Spandorfer SD, Goldstein J, pregnancy and implantation rates acupuncture. Am J Chin Med
Navarro J, et al. Difficult in an IVF program. J Assist Reprod 2003;31:481–8.
embryo transfer has a Genet 2002;19:14–8. 117. Paulus WE, Zhang M, Strehler E,
negative impact on the outcome of 111. Abusheikha N, Lass A, Akagbosu F, et al. Motility of the endometrium
in vitro fertilization. Fertil Steril et al. How useful is cervical after acupuncture treatment. Fertil
2003;79:654–5. dilatation in patients with cervical Steril 2003;80:131.
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Chapter | 11 |
ART complications
Assisted Reproductive Technology (ART) treatment is gen- form. This is accompanied by neovascularization in the
erally safe, but it is not without risks. Some patients may ovaries (angiogenesis).4 Newly formed and existing blood
suffer medication-related side effects. One common side vessels leak fluid into the abdominal cavity and sometimes
effect is when women over-respond to ovarian stimulation the pleural cavities and the pericardium, which may lead to
drugs, which may lead to a condition called Ovarian hypovolaemia (low circulating blood volume)4 and can
Hyper-Stimulation Syndrome (OHSS). When a woman even cause thrombosis, organ failure, and, in very rare
has severe OHSS, it can lead to cancellation of her embryo cases, death.
transfer procedure and cryopreservation of all her embryos,
hospitalization, or termination of her pregnancy, blood
clotting, kidney damage, ovarian torsion, and, in a very
few cases, death. However, because of better patient man- Orthodox medical management
agement practices, severe OHSS is now very rare. of OHSS
Multiple-gestation pregnancy (pregnancy with more
than one foetus) is still a very common complication fol- OHSS usually presents soon after egg retrieval in an ART
lowing ART treatment. Multiple-gestation pregnancies cycle or after ovulation in superovulation cycles, but it
put mothers’ and babies’ health and lives at risk. In terms can present later.5 OHSS can be classified according to
of ART’s long-term effects on women, currently there is when it presents:6
no evidence that ART has any effect on genital or breast can- • Early OHSS (9 days after oocyte retrieval) or
cer rates.1–3 • Late OHSS (9 days after oocyte retrieval)
Early onset OHSS tends to be mild and often self-limiting
whereas late onset OHSS is usually more severe and almost
OVARIAN HYPER-STIMULATION always associated with conception because hCG is neces-
SYNDROME sary for OHSS to develop. Mild OHSS affects up to 30%
of women and is usually managed by over-the-counter
painkillers and outpatient checkups.7 Severe OHSS affects
Introduction up to 2% of women and can be fatal if not appropriately
OHSS is a complication of In Vitro Fertilization (IVF) treat- managed.7
ment where, along with ovarian enlargement, the ovaries Any woman undergoing ART can develop OHSS, but the
produce too many (hypertrophic) follicles, with the result disease is associated with the following risk factors:
that fluid may leak and accumulate in the abdominal cavity • Patients less than 35 years old8
and chest. OHSS is not very well understood, but it is • Previous OHSS history8–10
believed to be a result of women producing too many • Low body weight5,9,11
intermediate-size follicles (10–14 mm in diameter on the • Oligomenorrhoea or amenorrhoea8
day of Human Chorionic Gonadotrophin (hCG) trigger • High Luteinizing to Follicle Stimulating Hormone
injection).4 Following egg retrieval, multiple corpora lutea ratio8
• High serum oestradiol (E2) levels (>2500 pg/mL or retrieval is recommended because a high dose of hCG is
9000 pmol/L)5 a known risk factor for developing OHSS.9
• More than 11 follicles of 10 mm diameter on the day of
The Orthodox medical management of OHSS is based on
hCG administration12
identifying women at risk of OHSS and taking preventative
• Polycystic Ovaries/Polycystic Ovary Syndrome
measures, such as:
(PCOS)5,8,9
• More common and severe when conception occurs6 or • Lower dose Gonadotrophin-Releasing Hormone
in multiple-gestation conceptions6 (GnRH) in high-risk women6 (75–150 IU/day)8
• Egg donors are more at risk8 • GnRH antagonist instead of agonist protocol6,8,9
OHSS is very strongly associated with the hCG hormone, • Co-treating women who have PCOS with metformin6,8
which is produced by the embryo after it is implanted • Coasting (withholding the hCG trigger for a few days
and rises rapidly. hCG adversely affects OHSS in a number until oestradiol drops to <2500–4000 pg/mL)6,8,13
of ways: • Cancelling embryo transfer and cryopreserving all
embryos6
• hCG supplementation during the luteal phase makes
Using dopamine agonists6,13,14
OHSS worse.9 •
• Avoiding hCG as luteal support6,13
• Pregnancy and, therefore, rising levels of hCG make
In Vitro Maturation13
OHSS much worse. Multiple-gestation pregnancy •
produces even higher levels of hCG, which is associated Once a woman develops OHSS, treatment depends on the
with more severe OHSS. severity of the symptoms. Table 11.1 provides staging and
• Using the lowest possible effective dose of hCG in IVF common signs and symptoms of OHSS, and Figure 11.1
cycles to trigger final oocyte maturation before egg provides an algorithm for managing OHSS patients.
292
Prevention/monitoring stage
Predisposing
High risk patients
TCM syndromes
Spleen Qi Deficiency Patient <35 years old Usual IVF acupuncture care
Kidney Yang Deficiency Previous OHSS history and
Heat (Full or Empty) Low body weight Treat predisposing
Dampness or Phlegm Oligomenorrhoea or amenorrhoea TCM syndromes
Stagnation (especially Liver Qi) High LH/FSH ratio
Blood Stasis PCOS/PCO
Egg donors
Acute stage
• Abdominal pain: mild, transient • Abdominal pain: severe, not • Symptoms become even more
relieved by painkillers improved with medication severe
• Abdominal distension: mild, • Abdominal distension: yes, • Vomiting: yes, prevents
only on ultrasound seen on physical examination ingestion of food or fluids
• Thirst: sometimes • Thirst: yes • Urination: severely reduced or
• Weight gain: <1 kg (2 lb)/day • Weight gain: ≥ 1 kg (2 lb)/day completely stopped
• Nausea: mild • Nausea: yes • Fainting
• Vomiting: sometimes • Vomiting: yes • Difficulty breathing
• Urination: normal • Urination: reduced • Signs of thrombosis or embolism
• Stools: normal or diarrhoea • Stools: diarrhoea
• Dizziness
• Rapid breathing (>20 bpm) or Refer urgently to accident
Advise patient to inform ART unit breathlessness and emergency unit
and • Rapid heart rate (>100 bpm) and
Treat with acupuncture daily Do not treat with acupuncture
according to TCM OHSS
syndrome differentiation Refer to ART unit
and and
Provide self-help advice Treat with acupuncture
if deemed safe by a
specialist doctor
and
Provide self-help advice
Re-assess
severity on
a daily basis
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Acupuncture for IVF and Assisted Reproduction
Mild OHSS is characterized by mild abdominal discom- • Phlegm/Damp (weight gain caused by sudden
fort, which improves with over-the-counter painkillers accumulation of fluids)
such as paracetamol.5 Women with mild OHSS should Acupuncture points that may be used include:
be monitored on an outpatient basis for signs of OHSS
• REN9, SP9, ST40:16 to drain Damp and resolve Phlegm
deterioration. Increased abdominal distension and pain,
• REN12, LIV3:16 to regulate Qi
rapid weight gain (1 kg (2 lb) a day), reduced urine out-
• KID2, LIV2:16 to clear Heat and Fire
put, and respiratory system symptoms such as shortness of
• KID14:17 to dispel the ‘four fullnesses’ (Qi, water, food,
breath or rapid breathing5 are common indications. An
and Blood Stagnation)
increase in symptom severity requires hospitalization and
• SP10:18 to move Blood Stasis
further investigations, such as ultrasonography, X-ray
• SP6:18 to resolve Dampness, regulate Qi, and move
scans, and laboratory tests. Treatment is supportive, includ-
Blood Stasis (contraindicated in confirmed pregnancy;
ing fluid and electrolyte management.
use SP10 instead)
If the condition is allowed to progress still further, most
major organs will be affected, and blood clots may form.
These patients require very intensive medical management.
OHSS patient management
Principles of management and treatment of OHSS include:
• Identifying patients at risk of OHSS (from both an
Acupuncture management of OHSS Orthodox and a TCM perspective)
• Prophylactic acupuncture treatment of patients
TCM view of OHSS identified at risk of developing OHSS
OHSS is a modern condition that almost always results • If OHSS develops, minimizing OHSS symptomatology
from ART treatment (apart from a few reported cases of and progression
spontaneous OHSS). Prevention is definitely better than cure when it comes to
OHSS commonly arises in patients with underlying managing patients at risk of developing OHSS. Extreme
pathology, including: caution and vigilance is required by less experienced acu-
• Spleen Qi Deficiency puncturists when managing OHSS in order to minimize
• Kidney Yang Deficiency its progression.
• Heat (Full or Empty) When treating patients at high risk of developing OHSS
• Dampness or Phlegm during the stimulation phase of the IVF treatment, the acu-
• Stagnation (especially Liver Qi) puncturist should place less emphasis on enhancing ovar-
• Blood Stasis ian response and more on supporting the Spleen and
Many fertility patients have underlying Liver Qi Stagnation Kidney functions of transforming and transporting Body
and also possibly Blood Stasis. Stagnation of Liver Qi can Fluids and on clearing Damp and Heat and moving Qi
be caused by side effects of medication, the emotional and Blood.
impact of subfertility and IVF, or pre-existing Liver Blood Although OHSS is more common in high-risk patients,
Deficiency. Stagnation of Qi is marked by mood changes, every patient should be monitored for signs of OHSS. If
tearfulness, or irritability during downregulation. the early warning signs become apparent, the patient
The accumulation of fluid, which features in OHSS, should be treated every other day in order to prevent OHSS
exacerbates Qi Stagnation. Severe obstruction of Qi will from developing. Practitioners need to look for early warn-
generate Heat. Pathological Heat can also cause Blood Sta- ing signs of OHSS, such as:
sis or make pre-existing Blood Stasis worse. Ovarian stim- • Any abdominal pain
ulation drugs commonly create Heat, Qi Deficiency, and/or • Any abdominal distension
Stagnation. • Weight gain
Interestingly, PCOS patients have a high risk of develop- • Nausea
ing OHSS, and, in TCM, they are often diagnosed with • Dry mouth with little desire to drink16
underlying Damp-Phlegm and/or Blood Stasis. This also • More than 11 follicles of 10 mm diameter on the day
suggests that Dampness, Phlegm, and/or Blood Stasis play of hCG administration12
a big role in the pathophysiology of OHSS. • Serum oestradiol levels >2500 pg/mL (>9000 pmol/L)
Once OHSS develops, it can be in a complex combina- Patients at risk of OHSS or patients who show early warn-
tion of any of the patterns below: ing signs should be provided with self-help advice, as out-
• Heat (thirst, scanty urine, constipation, dryness, and, in lined in Box 11.1.
some cases, fever) If OHSS develops, the severity should be assessed. If
• Stagnation of Qi and/or Blood (distension, nausea, OHSS is mild, acupuncture may help to reduce the symp-
pain, blood clots) toms and the risk of progression and, hence, optimize ART
294
ART complications Chapter | 11 |
OHSS patient self-help advice • Maintain light activity and avoid strict bed rest.5
• Contact your ART unit, and inform them of your symptoms. • Check weight daily and log it. Immediately report a weight
• Take over-the-counter medication, such as paracetamol, to increase of 1 kg (2 lb) per day to your doctor.5
help with pain. Avoid ibuprofen. • Record frequency and volume of urination.5 Report
• Drink until thirst is quenched,15 but drink a minimum of 1 L reduction in urination to your doctor.
of fluids a day.5 • Other symptoms that you need to report immediately to
• Ideal fluids to drink are any commercially available your doctor are dizziness, severe nausea and vomiting
electrolyte-supplemented drinks.5 where you cannot keep food or fluids down, severe pain that
• Avoid intercourse.5 does not improve with painkillers, shortness of breath,
• Avoid heavy lifting.5 fainting, and burning and swelling anywhere in the body.
295
Acupuncture for IVF and Assisted Reproduction
296
ART complications Chapter | 11 |
embryo transfer are similar.22 However, eSET is still not and reducing doses of gonadotrophins used for ovarian
favoured by many patients or by some fertility specialists. stimulation.
Conception rates following eSET, and, therefore, its In some countries, (multiple) foetal reduction is prac-
acceptance by patients and physicians, can be improved tised. This method reduces the risks associated with multi-
by developing better methods of identifying embryos with ple pregnancies by aborting one or more foetuses.
the highest implantation potential and by more accurately
identifying which patients would be the best candidates for
eSET. Many countries have issued guidelines and, in some Implications for fertility
cases, introduced legal limits on how many embryos
acupuncturists
should be transferred (see Table 11.2).
Other ways of reducing the chance of a multiple-gestation Although the main responsibility of a fertility acupunctur-
pregnancy include individualizing ART stimulation protocols ist is to advise patients that the number of embryos to be
Continued
297
Acupuncture for IVF and Assisted Reproduction
298
ART complications Chapter | 11 |
transferred rests with their fertility specialist, in clinical real- basis throughout pregnancy and ideally postdelivery. The
ity, many patients turn to us for advice because they trust aim of treatment is to continue addressing any imbalances
our opinion. As fertility acupuncturists, we are in a position identified before conception and to monitor patients for
to influence what choices our patients make. It is therefore any new emerging patterns. For more information about
our responsibility to ensure that we provide our patients how to manage patients during early pregnancy following
with accurate information about the risks and benefits of ART treatment, see Chapter 14.
multiple embryo transfer to help our patients make an
informed decision. It is important to note that, although
fertility patients present for acupuncture at all stages of their
ART treatment, many come after one or more failed ART SUMMARY
cycles. For the majority of these patients, eSET is not the
best option. The primary objective of ART treatment is to help a couple
Our secondary role is to look after our patients once they conceive. However, the treatment should be as safe as pos-
are pregnant and help to minimize the risks associated with sible for the mother and any resulting babies. Acupuncture
multiple-gestation pregnancies, both prenatally and post- practitioners need to be aware of the major risks of ART and
natally. That usually means treating patients on a regular manage patients as safely as possible.
REFERENCES
1. Land JA, Evers JLH. Risks and 8. Radunovic N. OHSS – old dilemma severity of OHSS in IVF/ICSI
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ESHRE consensus meeting. Hum Reproductive Medicine Across Update 2010;16:459–66.
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2. Brinton LA, Trabert B, Shalev V, et al. 9. Kasum M, Oresković S. New Gynaecologists. The management of
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Fertil Steril 2013;99:1189–96. 10. Humaidan P, Quartarolo J, 16. Carman N. The treatment of ovarian
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Gezondheidszorg; 2010. p. 41–56 12. Lee TH, Liu CH, Huang CC, et al. The Spleen channel. In: A manual of
[chapter 2]. Serum anti-Müllerian hormone acupuncture. England: Journal of
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7. ASRM. Assisted reproductive 2010;27:121–8. 20. Research and evidence – facts
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Report of the ASRM. Birmingham, Hassan MA, et al. Can dopamine http://www.oneatatime.org.uk/126.
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21. Barnhart KT. Epidemiology of male oneatatime.org.uk/372.htm 26. Canadian Fertility and Andrology
and female reproductive disorders [accessed 23 September 2012]. Society. Reduction of multiple
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300
Chapter | 12 |
Managing the patient with a complex
medical history
(a) (b)
Figure 12.1 Estimates of pregnancies lost at different stages from ovulation to full term; (a) natural conceptions and (b) IVF
conceptions.3,4
Uterine and maternal factors an ultrasound scan.12 There is a growing body of evidence
that hysteroscopy significantly increases the clinical preg-
As described in Chapter 3, the blastocyst is only able to
nancy rate in a subsequent IVF cycle.11,13 This seems to
implant when the endometrial surface is receptive to the
be the case even if no pathology was detected or treated, sug-
embryo. This phase is referred to as an ‘implantation win-
gesting that the procedure itself has therapeutic value.10,11
dow’, and it lasts for approximately 48 h, but the exact cycle
days vary in different women and in natural and stimulated
cycles.6 Approximately two-thirds of RIFs are attributed to Endometrial injury (biopsy or ‘scratch’)
defective endometrial receptivity and one-third to the Endometrial injury (biopsy or ‘scratch’) in the cycle before
embryo itself.7 Endometrial receptivity can be compro- an ovarian stimulation cycle appears to improve clinical
mised by a number of factors. pregnancy rates in patients with unexplained RIF. A
meta-analysis of seven studies and 2062 participants
Anatomical abnormalities and hysteroscopy showed that patients who had an endometrial biopsy
Congenital uterine abnormalities are found in 5.5% of the had a 38.1% clinical pregnancy rate compared to 36.8%
normal female population, 8% of infertile women, 13.3% in patients who only had hysteroscopy and 18.4% in
of women with a history of miscarriages, and 24.5% of patients who had no hysteroscopy or biopsy.14 There was
women with a combined history of infertility and miscar- not enough evidence to make recommendations as to
riages.8 Commonly, as part of the initial infertility investi- exactly when in the preceding cycle the biopsy should be
gations, the uterus is assessed by transvaginal ultrasound or done, nor if one or more injuries are necessary.14 The endo-
hysterosalpingography (HSG). However, uterine abnor- metrial injury initiates changes to the endometrium, the
malities might be missed during the initial infertility immune system, and gene expression, all of which help
investigations.9,10 with endometrial receptivity.14
In their review, Makrakis and Pantos found that the inci-
dence of abnormal hysteroscopic findings in women with a Interval (sequential) embryo transfer
history of RIFs is between 25% and 50%.11 Common intra- Interval (sequential) embryo transfer is where two embryos
uterine findings in RIF are endometrial polyps, endome- are transferred at least 24 h apart (for example, one on day
trial and endocervical adhesions, endometritis, uterine 2 and one on day 5 after egg retrieval). Several studies have
septa, and submucous myomas/fibroids.10 shown that interval embryo transfer increases implantation
Hysteroscopy is a direct and definitive method of asses- rates.15–18 The endometrial receptivity and maturation var-
sing intrauterine pathology (see Chapter 4 for more ies on different days of the luteal phase and is not an exact
details). When compared with transvaginal ultrasonogra- science. By transferring embryos on two different days, it is
phy (which is the usual first-line non-invasive uterine cavity hypothesized that the chance of transferring the embryos
assessment), hysteroscopy has been shown to detect 19%12 when the endometrium is at its peak level of receptivity
to 22.2%10 more abnormal findings, which were missed by is increased.18,19
302
Managing the patient with a complex medical history Chapter | 12 |
Uterine/maternal
Paternal factors Embryo factors Other factors
factors
Number of Psychological
Hydrosalpinges embryos factors
transferred
Genetic
Endometritis
abnormalities
Subclinical
infections
Immune
diseases
Thrombophilia
Age
303
Acupuncture for IVF and Assisted Reproduction
Endometriosis Thrombophilia
A meta-analysis of 22 studies found that the pregnancy rate Thrombophilia is a group of different disorders that cause
of women undergoing IVF because of endometriosis- blood to clot abnormally.39 Thrombophilia is linked to
related subfertility was almost half that of women with recurrent pregnancy loss and other pregnancy complica-
other pathologies.24 Endometriosis is thought to affect tions, such as foetal growth restriction, stillbirth, and severe
endometrial receptivity as well as the development of the preeclampsia.39 Some studies have shown that thrombo-
egg and the embryo.24 Chapter 8 discusses endometriosis philia is associated with RIF,40–43 yet other studies failed
in greater detail. to find such a link.44,45 A 2006 literature review by the
American Society for Reproductive Medicine (ASRM) con-
cluded that antiphospholipid antibodies (acquired throm-
Hydrosalpinges bophilia) do not negatively affect IVF success rates.46
Hydrosalpinx is defined as a ‘collection of watery fluid in Low molecular-weight heparin is the first-line treatment
the uterine tube, occurring as the end-stage of pyosal- for thrombophilia disorders. Several studies have investi-
pinx’.25 It is strongly associated with reduced implanta- gated whether heparin improves pregnancy rates in
tion.25 The fluid within the tube is believed to be toxic to patients with a history of RIF. Some studies have shown
the embryo. An alternative explanation is that the fluid improved success rates,47–49 and others failed to demon-
mechanically washes out the embryo.25 Laparoscopic sal- strate an improvement.50,51
pingectomy (removal of the affected fallopian tube(s)) One of the criticisms of many studies examining the link
prior to IVF has been shown to be beneficial.25 between thrombophilia and RIF is that women without
clear thrombophilia are often included in the analysis.
Better-quality studies are needed where only women with
Endometrial thickness confirmed thrombophilia disease are included in the
A retrospective analysis of 2464 IVF cycles found that there research methodology.
was a linear relationship between endometrial thickness on
the day of hCG administration and pregnancy rates, with a Maternal age
29.4% pregnancy rate in women who had linings of As women age, the rate of aneuploidy of embryos increases
6 mm and 44.4% in women who had linings of significantly.52 Maternal age is an independent factor in the
17 mm.26 Another retrospective analysis of 768 medi- success rates of ART treatment when patients use their own
cated FET cycles found that implantation, clinical preg- (autologous) eggs.53 A large retrospective analysis of
nancy, ongoing pregnancy, and live birth rates were all 36,412 ART cycles found that for women aged 30 or older,
significantly higher in women with endometrial thickness each additional year was associated with an 11% reduction
measuring between 9 and 14 mm on the start day of pro- in pregnancy rates and a 13% reduction in live birth rates.53
gesterone supplementation.27 Chapter 10 discusses endo- In a retrospective analysis of 1263 women aged 40 or
metrial lining thickness in greater detail. older undergoing 2705 ART cycles, cumulative birth rates
varied from 28.4% if starting treatment at the age of 40
to 0% by age 46.54 The effect is even more pronounced
Infections in women aged 43 or older, with live birth rates of 1.1%
Infections introduced inside the uterus during the embryo in women aged 43 or older55 and in women aged 45 or
transfer procedure have been implicated in RIF.28,29 The older only 0.5%56 to 0.7%.57
use of antibiotics before embryo transfer has not been However, what may give some hope to older prospective
shown to increase pregnancy rates.28,30 Cleaning the cervix mothers is that other factors such as menstrual cycle length
and vagina with saline liquid may help to reduce the pos- may be even more important than maternal age. A prospec-
sibility of bacterial contamination.28 tive study of 6271 IVF/Intracytoplasmic Sperm Injection
Controversially, menstrual blood can be tested for the (ICSI) treatment cycles showed a direct significant relation-
presence of ‘hidden’ intrauterine infections such as chla- ship between mean cycle length and implantation, the
mydia, which a standard vaginal swab is believed to miss. response to ovarian stimulation, and pregnancy and live
A course of very strong antibiotics is prescribed for patients birth rates even after adjusting for women’s age, with live
who test positive for infection(s). birth rates almost double in women who had cycle lengths
of >34 days compared with women who had cycle lengths
of <26 days.58
Immune disease The grade of an embryo rather than a woman’s age is a
Several different immune conditions may be associated better predictor of pregnancy rates following IVF according
with RIF.31–38 However, the evidence is mixed and, for to the results of a prospective study of 10,000 embryo
some conditions, controversial. transfers.59
304
Managing the patient with a complex medical history Chapter | 12 |
Mild IVF (see Chapter 9), androgen/dehydroepiandros- Blastocysts versus day 2 versus day 3 transfer
terone supplementation, preimplantation genetic screen- A Cochrane review of 23 RCTs concluded that blastocyst
ing (PGS), and egg donation are possible strategies for (day 5/6) transfer is associated with increased live birth
dealing with advanced maternal age and IVF.60 Embryo rates when compared to cleavage (day 2/3) stage embryo
banking is another viable strategy.61 transfer.74 Another Cochrane review assessed day 2 and
day 3 transfers and found no difference in live birth rates
between them.75 However, day 2 transfer may produce bet-
Male factor ter results in poor responders.76,77
Male factor is associated with high order ( 6) RIFs.62 High
levels of sperm DNA fragmentation is linked to reduced Zygote Intra Fallopian Transfer
pregnancy rates following IVF63,64 and IVF/ICSI.65,66
It has been suggested that Zygote Intra Fallopian Transfer
DNA fragmentation may be due to advanced paternal age
(ZIFT) may be an effective alternative to standard IVF in
or other environmental factors, increased levels of reactive
patients with RIF,78 the presumption being that the embryo
oxygen species (ROS), toxins, varicoceles, and exogenous
would develop better in a natural environment and that
heat.67 Some authors recommend that couples who have
ZIFT helps to overcome issues of difficult embryo trans-
RIF have the man’s sperm cells tested for DNA fragmenta-
fers.71 However, a meta-analysis of 6 RCTs and 548 cycles
tion.68 However, due to the low predictive ability of DNA
found no difference in implantation rates or pregnancy
fragmentation testing to identify subsequent pregnancies,
rates between ZIFT and IVF.79
the ASRM does not recommend routine use of the
procedure.69
The use of the Intracytoplasmic Morphologically Number of embryos transferred
Selected Sperm Injection (IMSI) may help to overcome In the United Kingdom over the past three decades, the
high DNA fragmentation problems (see Chapter 6 for incidence of multiple pregnancies has increased consider-
details about ICSI and IMSI).68 For example, in one very ably. In 1978 they accounted for one in every 100 births,
recent cohort study, it was found that using IMSI in while by 2004 one in every 67 births was a multiple preg-
patients who failed to conceive following ICSI increased nancy.80 Many other countries have seen similar increases.
their chances of pregnancy and live birth rate almost However, there is a greater risk of morbidity81,82 and mor-
threefold.70 tality82 in multiple-gestation pregnancy babies conceived
Chapter 7 provides information on the possible use of following ART. Multiple-gestation pregnancies also
antioxidant supplements in cases where there is DNA dam- increase the risk of maternal morbidity. To reduce the rates
age caused by ROSs. In severe cases of male factor genetic of multiple-gestation pregnancies following ART, many
abnormalities, donor sperm may be required. countries have issued guidelines and some countries have
introduced legal limits on how many embryos should be
transferred (see Chapter 11).
Embryo factors However, research shows that elective single embryo
transfer (eSET) has a lower rate of live birth. A meta-analysis
Zona hardening and assisted hatching by Baruffi et al. concluded that fresh double embryo transfer
Assisted hatching may be helpful in patients with RIF (see (DET) resulted in 1.64–2.60 times greater ongoing preg-
Chapter 6 for more details on assisted hatching). nancy rates and 1.44–2.42 times greater live birth rates
compared to eSET.83 A Cochrane review the same year
Inadequate culture conditions concluded that eSET is associated with lower live birth rates
when compared with DET.84 Analysis of 124,148 IVF cycles
The quality of culture media used by the fertility clinic may
showed that the live birth rate in women aged 40 was
affect embryo development and therefore subsequent
significantly lower with eSET compared to DET.85 However,
implantation rates.71,72 There are many different culture
live birth rates did not increase with three embryos, but was
media available, containing between 11 and more than 30
associated with an increased risk of perinatal morbidity.85
different components.72 A recent meta-analysis of 22 RCTs
Therefore, in couples with RIF a DET may maximize the
that evaluated 31 different formulations could not make
chances of a live birth, while also balancing the risks asso-
any recommendations as to which media produce better
ciated with a multiple-gestation pregnancy.
results.73 This was in part due to nearly all trials comparing
different culture media and also studies reported different
outcome measures (some reported live birth rates and some Genetic causes: Parental
clinical pregnancy rates).73 The authors of the review con- Chromosomal abnormalities are found in 1.14%86 to
cluded that more better-quality studies are needed and 1.3%87 of subfertile female partners and 1.5% of male
new and better culture media need to be developed.73 partners.87 This is a higher incidence than in the general
305
Acupuncture for IVF and Assisted Reproduction
population.86,87 When comparing the incidence of chro- Non-invasive embryo assessment (morphokinetic
mosomal abnormalities in patients with RIF (transfer of analysis)
10 embryos) and 3 consecutive first-trimester miscar-
Normally, embryos are assessed by an embryologist at dis-
riages, the rates of chromosomal abnormalities were
tinct points in time, usually chosen for the convenience of
2.5% in RIF and 4.7% in miscarriage patients.88 In patients
the clinical facility, rather than for biologically relevant rea-
with 16 RIFs and 15 embryo transfers, the rate of paren-
sons.94 Identification of better-quality embryos is now pos-
tal chromosomal abnormalities is even higher at 15.4%.89
sible with new non-invasive technologies. For example,
Therefore, it is recommend that karyotyping should be
time-lapse microscopy (TLM) has been developed, where
undertaken in RIF patients.88,89
through an embryoscope an embryo’s development is
If a partner is found to have a structural genetic abnor-
monitored by capturing frequent images (every 20 min,
mality, he or she may be offered preimplantation genetic
5 min, or even at 10 s intervals).94 From these images,
testing (PGT), amniocentesis, or chorionic villus sampling
the embryo’s appearance (morphology) and its cellular
to detect genetic abnormalities in offspring. Available inter-
development (kinetics) are analysed either by an embryol-
ventions include preimplantation genetic diagnosis (PGD)
ogist or by computer software (e.g., Early Embryo Viability
or the use of donor gametes.67 Comparative genomic
Assessment or EEVA™), with the procedure known as mor-
hybridization (CGH), however, should not be offered to
phokinetic analysis.95,96
patients with RIF, because it cannot detect balanced
A recent study by Campbell et al. showed that TLM anal-
translocations.68
ysis can be used to predict embryo aneuploidy.97 If the first
cellular division happens before 26 1 h in ICSI and
Genetic abnormalities: Embryo 28 1 h in IVF, this is associated with better numbers
and quality of blastocysts and higher pregnancy rates.98
Some couples experience RIF, even after the transfer of
This information could be potentially missed with tradi-
seemingly good-quality embryos. Conceivably, these
tional embryo monitoring methods, whereas with TLM
embryos may be genetically abnormal. PGS is a proce-
monitoring this would be accurately recorded, and
dure where one or more nuclei from eggs or embryo cells
embryos that reach the relevant developmental milestones
(blastomeres or trophoectoderm) are removed for
at the right time would be transferred.
genetic testing.90
There are two main types of genetic screening of embryos:
PGD and PGS. PGD is recommended for patients at high Other causes
risk of transmitting a genetic or chromosomal abnormality
to their offspring.90,91 PGS is reserved for couples who are Treatment protocol
known or presumed to have normal chromosomes, but their Tailoring the stimulation protocol has been suggested to help
embryos are still screened for aneuploidy.90 The ESHRE improve implantation rates.71,78,99 For example, the use of a
recommends PGS for IVF patients with a history of RIF, mis- Gonadotrophin Releasing Hormone (GnRH) agonist has
carriages (but normal parental karyotyping), and in women been proposed to be preferable in poor responders100 and
of advanced maternal age.1 However, the ASRM currently in RIF.101 However, there is little evidence to suggest that
does not recommend PGS in patients with RIF due to the any particular protocol is the best. For example, a 2011
contradictory evidence base for its ability to help improve Cochrane review compared the use of GnRH antagonist pro-
pregnancy rates.90 tocol against the GnRH agonist protocol. No statistically sig-
Another method of genetic screening is Fluorescence In nificant difference in live birth rate was found. However, there
Situ Hybridization (FISH). FISH is used to check for miss- was a significant reduction in the incidence of Ovarian Hyper-
ing or excessive chromosomal material in eggs (if the stimulation Syndrome (OHSS) with GnRH antagonist proto-
female partner is a carrier) or in the embryo (if both part- col. Thus the GnRH antagonist protocol is probably more
ners are carriers) in patients known to have genetic abnor- suitable for women at risk of OHSS.102 There may be a case,
malities.90 FISH can also be used for embryo sexing for however, for trying a different protocol in patients with RIF or
x-linked diseases or social reasons such as gender selec- with a history of poor ovarian response, in case a new proto-
tion.92 However, the application of FISH is limited by col produces a different outcome in their individual cases.
the number of chromosomes it can examine93 and is not The dose of ovarian stimulation medication should also
recommended.71,90 be individualized on the basis of patient’s ovarian reserve
The CGH genetic screening method may overcome markers (Follicle Stimulating Hormone and Anti-Müllerian
some of the limitations of PGS and FISH.71 CGH cannot Hormone levels and antral follicle count scan results) and
detect all types of abnormalities.93 It is a time-consuming the patient’s previous history of response to stimulation
procedure with the embryos needing to be cryopreserved. medication.
Newer methods of genetic embryo screening are emerg- While synthetic progesterone is superior to micronized pro-
ing.93 However, it will be some time before evidence is gesterone, there is no evidence that any particular way of
available about their effectiveness. administering progesterone supplementation is superior.103
306
Managing the patient with a complex medical history Chapter | 12 |
307
Acupuncture for IVF and Assisted Reproduction
Uterus in facilitating conception is also impaired. Kidney thereby averting luteal regression. Heart pathology com-
(and Spleen) Yang Deficiency can also adversely affect promises the embryo’s vitality and ability to initiate, and
the luteal phase, thus impairing implantation.113 therefore facilitate, implantation, and the mother is unable
As already discussed, a considerable proportion of RIFs to respond. Table 12.1 lists signs and symptoms and treat-
can be attributed to the quality of embryos (pre-conceptual ment of Heart pathology.
factors) and the interaction between the embryo and its
mother. The transfer of embryos that are weak in Kidney
Jing (Essence) (for example, due to parental weakness of Spleen pathology
Jing (Essence) being passed onto the embryos) fails to Spleen Qi Deficiency weakens the Extraordinary Vessels
resolve such deficiency and may therefore result in a fail- and reduces the nourishment available for the survival of
ure. Furthermore, in these cases, maternal Jing (Essence) the embryo. Spleen Qi Sinking fails to hold the embryo
is likely to be weak, so the embryo(s) are thus transferred in the Uterus. Table 12.1 lists signs and symptoms and
into an environment unfavourable for conception and the treatment of Spleen pathology.
growth.
Congenital anatomical uterine anomalies, which are
common in patients with RIF, may well indicate congenital Blood Stasis
Kidney pathology. However, it is unlikely that we can cor- Free flow of Blood is required for the embryo’s develop-
rect these with acupuncture. Table 12.1 lists signs and ment and implantation into the endometrium. Blood Sta-
symptoms and treatment of Kidney pathology. sis blocks the flow of Blood and Qi, thereby reducing the
quality, composition, and regeneration of Blood.112 Blood
Liver pathology Stasis damages the Ren and Chong Mai (Conception and
The Chong and Ren Mai (Penetrating and Conception Penetrating Vessels) and the Uterus.112 Qi Stagnation
Vessels) supply and coordinate Qi, Blood, and Jing (Essence) and Blood Stasis affect the receptivity of the endometrium
to the Uterus to support the embryo’s gestation.116 Liver to the blastocyst and early pregnancy loss may result.
Blood Deficiency and Qi Stagnation can alter the amount, Table 12.1 lists the signs and symptoms and the treatment
flow, and quality of Qi and Blood circulation in the Extraor- of Blood Stasis pathology.
dinary Vessels.116 When the Uterus lacks the optimal level of
nourishment, ultimately so may the embryo. Stagnation
blocks Qi and Blood in the Uterus and prevents implantation. INTERESTING FACTS
The embryo needs to attach to the endometrium and
establish a stable connection to receive nutrition. Blood BLOOD STASIS AND INFERTILITY
Deficiency and Stagnation make this difficult. Successful In medieval China, women unable to conceive were treated
attachment also depends on changes in the endometrium. with vaginal suppositories and Uterus rinsing decoctions to
The endometrium can fail due to disordered functioning of correct Blood dysfunction in the Uterus.119
Qi and Blood in the Uterus. Blood Deficiency may reduce
the thickness of the endometrial lining, thus adversely
affecting implantation.113,117 Liver Qi Stagnation,113 par- Cold
ticularly when the woman is more acutely distressed at Cold harms Blood.120 Cold, combined with Damp, can
the time of the transfer, superimposed on chronic stagna-
block the Uterus, thereby damaging the Chong and Ren
tion, may contribute to problems at the time of the embryo
Mai (Penetrating and Conception Vessels). A Cold-Uterus
transfer and reduce pregnancy rates. Fibroids and polyps
pathology prevents the free flow of Blood and coagulates
are associated with Liver Qi Stagnation and Spleen Defi-
and blocks Blood and Jing (Essence). Table 12.1 lists the
ciency, although fibroids and polyps may also be associ-
signs and symptoms and the treatment of Cold pathology.
ated with generalized Qi Stagnation and Blood Stasis or
Yin Deficiency and Empty-Fire Blazing.118 Table 12.1 lists
the signs and symptoms and treatment of Liver pathology. Phlegm-Damp
Fluids can become overabundant and overwhelm the
Heart pathology Uterus112 and the embryo. Phlegm-Damp generates con-
Heart Qi or Blood Deficiency and Stagnation frequently gestion and poor circulation of Jing (Essence), Qi, and
arise from the psychological distress of repeated failed Blood. Therefore, the embryo loses the essential nourish-
IVF cycles. This can impair the vitality, circulation, and ment required for its growth and implantation. Phlegm-
quality of Blood and Qi in the Uterus and reduce the Damp can also obstruct the Uterus, so that the blastocyst
embryo’s chances of implantation. lacks a clear attachment site. Table 12.1 lists the signs
The embryo signals its existence to the mother. Signalling and symptoms and the treatment of Phlegm-Damp
ensures that the embryo’s existence is acknowledged, pathology.
308
Table 12.1 Syndrome differentiation and treatment in RIF patients
Continued
Acupuncture for IVF and Assisted Reproduction
Blood-Heat
Case study—cont’d
Heat harms Qi120 and Blood. Blood-Heat negatively affects
implantation.117 Heat/Fire forces the flow of Blood, stimu-
On the seventh IVF cycle, Louise decided to try
lates and heats Blood, and can in some cases create Blood
acupuncture treatment alongside IVF in order to increase
Stasis or Phlegm. Maternal Heat ‘parches’ or ‘scorches’ the
the chances of her embryos implanting. (Her husband was
embryo.121 Table 12.1 lists signs and symptoms and treat-
reluctant to have acupuncture.) Louise’s TCM diagnosis was
ment of Blood-Heat pathology. Spleen Qi Deficiency. She conceived following this
treatment cycle.
Two years later Louise and her husband decided to try for
The acupuncturist’s role in the management a sibling for their son. The original syndrome had now
progressed. She was suffering with Damp alongside pre-
of RIF existing Spleen Qi Deficiency as well as Liver Blood
When treating RIF patients, acupuncturists may need to: Deficiency and had minor signs of Kidney pathology,
presumably in part caused by breastfeeding her baby for a
• Review the Orthodox medical management of their
patients and potentially make recommendations. year, being drained from looking after her baby and being
2 years older. Treatment now focused on treating these
• Refer for RIF tests and investigations where syndromes in addition to IVF acupuncture protocols. Louise
appropriate.
became pregnant with her second child and now has two
• Provide or reinforce advice on pre-conceptual care to healthy children.
increase the chances of successful ART treatment.
• Help to manage patients’ stress levels.
Figure 12.3 provides a detailed algorithm on RIF patients
management, and Appendix I provides an IVF audit tool,
which can be used to help review each case. MISCARRIAGES AND
PREGNANCY LOSS
310
Managing the patient with a complex medical history Chapter | 12 |
Step 1 Step 2
Review lifestyle factors Review basic tests and investigations
(see Chapter 7) (see Chapter 4)
Step 3 Step 4
Review advanced tests and investigations Review previous ART treatment
(see Chapters 4 and 12) (see Chapter 10)
Step 6
Make recommendations
(see Chapter 12)
311
Acupuncture for IVF and Assisted Reproduction
are classified according to when they happen and the num- who miscarry are less likely to have had their miscarriage
ber of consecutive miscarriages: caused by uterine issues. Up to 60% of first-trimester spon-
• Spontaneous clinical miscarriage (also referred to as taneous miscarriages are believed to be due to embryonic
a spontaneous abortion): a clinical pregnancy loss chromosomal abnormalities.67
before 24 weeks’ gestation.123 Both maternal and paternal ages are independent risk fac-
• Spontaneous preclinical miscarriage: a pregnancy that is tors for miscarriages.123 One study analysed 634,272
diagnosed by the detection of hCG in serum or urine, women and 1,221,546 pregnancy outcomes and found that
but that does not develop into a clinical pregnancy.124 the rate of spontaneous miscarriages was directly associated
• Missed miscarriage (also known as a blighted with maternal age (Figure 12.4).127 In this study the rate of
ovum): a clinical miscarriage where the pregnancy is spontaneous miscarriages in women under 35 years old was
nonviable but is not expelled spontaneously.122 around 7%, rising to 27% in women older than 45 years of
• Recurrent miscarriages (RMs): usually, two or more age (Figure 12.4).127 However, the risk of embryo aneu-
consecutive clinical pregnancy losses.67,122 However, ploidy is lower in women with RMs, irrespective of mater-
some experts feel that a diagnosis of RMs should only nal age.67,128 This is because chromosomal abnormalities
be made after three or more consecutive are unlikely to cause three miscarriages in a row.
miscarriages.123 Less than 5% of couples will Paternal age is implicated in miscarriages.123 In one
experience two consecutive miscarriages and only 1% study that retrospectively analysed outcomes of 3174 preg-
will experience three or more.67 nancies, it was found that the risk of miscarriages was great-
est in couples where a woman was aged 35 years and a
Different expert bodies offer different recommendations
man aged 40 years.129
regarding the timing of RM investigations. The ASRM rec-
ommends that clinical investigations should be undertaken
following two first-trimester pregnancy losses.67 In the
United Kingdom, the Royal College of Obstetricians and Parental genetic abnormalities
Gynaecologists (RCOG) recommends investigations after Parental genetic abnormalities are observed in approxi-
three consecutive first-trimester miscarriages or after one mately 4% of couples with RM (compared to 0.2% in the
second-trimester miscarriage.123 general population).130 It is recommended that both part-
The rates of clinical miscarriages following IVF are ners in a couple with a history of RM should undergo
higher compared to the rates of miscarriage in natural con- peripheral karyotyping in order to exclude a possibility of
ceptions (a range of 21.7–23.5% vs. a range of 10–15%, any balanced structural chromosomal abnormalities such
respectively).125,126 There are several hypotheses that as balanced reciprocal translocations and Robertsonian
attempt to explain these different rates. One hypothesis translocations.67
posits that women undergoing ART treatment tend to test If a partner is found to have structural genetic abnormal-
earlier. If they miscarry shortly after testing positive, they ity, she may be offered PGT, amniocentesis, or chorionic
will know that they were pregnant, whereas in a natural villus sampling to detect genetic abnormalities in the off-
conception, pregnancy may have gone unnoticed and spring. Treatment options include PGD or use of donor
any bleeding would be perceived as a late period.125 gametes. Genetic counselling is also indicated. Routine pre-
Another hypothesis is that women who get pregnant fol- implantation embryo aneuploidy screening is not currently
lowing IVF on average tend to be older. The risk of miscar- recommended.67 Chapter 4 provides more information
riages is greater in older women. For example, a rate of about parental genetic testing and embryo genetic testing
17.6% in women younger than 30 years old rising to a rate is described later in this chapter.
of 39.1% in women more than 40 years old.125 The under-
lying pathology that causes subfertility is also implicated in
miscarriages.125
Anatomical factors
Congenital uterine abnormalities are more common in
Causes of miscarriages women with a history of RMs, especially second-trimester
pregnancy loss. Congenital uterine abnormalities are found
Embryo genetic abnormalities in 12.6% of women with RM (compared to 4.3% of women
and parental age with normal fertility).67 Congenital uterine abnormalities
Age-related miscarriages are thought to be caused by the are also associated with preterm labour, foetal malpresenta-
aneuploidy of embryos, where an embryo losses or gains tion, and increased risk of caesarean delivery.67
one or more chromosome(s).124 Pregnancies in older The most common congenital uterine abnormalities
women, who are recipients of an egg donated by a younger associated with miscarriages are:67
woman, have similar rates of miscarriages to that of youn- • Uterine septum (risk of pregnancy loss 44.3%)
ger women.67 This indicates that age has a detrimental • Bicornuate uterus (risk of pregnancy loss 36.0%)
effect on the quality of eggs and embryos and that women • Arcuate uterus (risk of pregnancy loss 25.7%)
312
Managing the patient with a complex medical history Chapter | 12 |
20%
15%
10%
5%
0%
12–19 20–24 25–29 30–34 35–39 40–44 45
Maternal age
A uterine septum (where the uterine cavity is partitioned by presents as amenorrhoea or very scant menstruation. Diag-
a complete or incomplete wedge like longitudinal septum) nosis is confirmed by HSG or hysteroscopy.132 Minor adhe-
is the most common uterine abnormality with the highest sions can be surgically corrected, but extensive dense
risk of pregnancy loss. A complete septum divides the cervix fibrosis suggests a poor prognosis.130
into two. Research shows that uterine septum is associated In their extensive literature review Li et al. (2002) con-
primarily with early (13 weeks) and less so with late (14– cluded that submucous fibroids significantly compromise
22 weeks) miscarriages, and with pregnancy losses of reproductive outcome, whereas intramural and subserosal
around 54% and 12%, respectively.131 Patients who are may possibly mildly compromise the reproduction out-
found to have uterine septum prior to pregnancy would comes. Removing submucous and intramural fibroids
benefit from metroplasty, surgical resection of the septum. reduces the rate of miscarriages.130
Women with a bicornuate uterus (a ‘heart shaped’ uterus) The ASRM recommends that serious acquired uterine
have significantly higher rates of infertility, miscarriages, and defects should be surgically corrected, if feasible. If surgical
combined infertility and miscarriages, compared to women repair is not possible, ASRM recommend the use of a ges-
in the general population, with a frequency of 0.4% (normal tational carrier.67
population) vs. 1.1% (infertility) vs. 2.1% (miscarriages) vs. Cervical weakness or insufficiency is a condition where
4.7% (infertility and miscarriages).8 the cervix shortens and dilates prematurely; this is strongly
An arcuate uterus is where the uterine fundus has a con- associated with second-trimester pregnancy losses.123
cave shape toward the uterine cavity and is mainly associ- Section ‘Preterm birth and cervical insufficiency’ discusses
ated with second-trimester miscarriage.123 this in greater detail.
Congenital uterine abnormalities are usually picked up
by HSG and can be evaluated more fully by 3D ultrasound
imaging, hysteroscopy, or Magnetic Resonance Imaging Infections
scan. The RCOG recommends that all women with recur- The ASRM acknowledges that Ureaplasma urealyticum,
rent first-trimester miscarriages and all women with one Mycoplasma hominis, Chlamydia, Listeria monocytogenes,
or more second-trimester miscarriages should have their Toxoplasma gondii, Rubella virus, Cytomegalovirus, and her-
uterine cavity assessed using ultrasound.123 Any suspected pes virus are found more frequently in vaginal and cervical
abnormalities should be evaluated further using hysteros- cultures and serum in women with a history of spontane-
copy, laparoscopy, or a 3D ultrasound scan.123 ous miscarriages.67 However, the ASRM does not recom-
Acquired uterine conditions, although the existing evi- mend routine infection testing in RM or the use of
dence is inconclusive, including such conditions as adhe- empiric antibiotics due to lack of evidence that these infec-
sions, Asherman syndrome, fibroids, and polyps, have tions actually cause RM.67
been suggested to increase the risk of pregnancy loss. This ASRM approach is not supported by all experts. An
Asherman’s syndrome is where the uterine cavity is alternative approach they suggest is that patients with RM
affected by post-traumatic adhesions,130 for example, should be screened for vaginal infections and daily vaginal
post-abortal or postpartum curettage.132 These adhesions pH measurements should be done.133 More controver-
affect endometrial receptivity resulting in a foetal survivial sially, menstrual blood can be tested for presence of ‘hid-
rate estimated to be 30%.132 Asherman syndrome usually den’ intra-uterine infections such as Chlamydia, which
313
Acupuncture for IVF and Assisted Reproduction
314
Managing the patient with a complex medical history Chapter | 12 |
Immunological factors
Red flag
Immune factors, whereby the maternal immune system
fails to adapt to the developing embryo, resulting in rejec-
Bleeding and/or abdominal pain in a woman
tion, may be involved in some cases of RM.130 See of reproductive age
section ‘Reproductive Immunology’ for discussion on var-
ious immune conditions and their association with Any woman of reproductive age experiencing vaginal
bleeding and/or abdominal pain should be referred to an
implantation failure and pregnancy loss.
EPU if known to be pregnant or to a doctor if not known to
be pregnant.
Urgent referral to an Accident and Emergency (A&E)
Male factor
department is indicated if the pain is severe and
Two recent meta-analyses showed that the rate of miscar- accompanied by:
riages is significantly higher in patients with high sperm ® Dizziness or fainting
DNA fragmentation.149,150 Therefore, sperm DNA fragmen- ® Rapid pulse
tation testing should be undertaken in patients with RM or ® Low blood pressure
even before undergoing ART.150 Antioxidants may help to ® Severe vaginal bleeding (more than 1 pad/h)
repair some DNA damage (see Chapter 7 for more details). ® Severe pelvic pain
® Temperature above 38 C (100.4 F)
Environmental, lifestyle, and nutritional
factors Pregnancy viability assessment
Several environmental factors have been linked with mis- The diagnostic classification of miscarriages depends on
carriages, including obesity, caffeine intake, alcohol intake, the clinical findings (see Table 12.2).
smoking, illicit drug use, medication, occupation factors, The initial assessment of the viability of a pregnancy
stress, and nutritional deficiencies. These are discussed in should include a medical history, a bimanual examination,
greater detail in Chapter 7. and a urinary hCG test. However, while this assessment
Hyperhomocysteinaemia (elevated homocysteine levels) may help physicians in their decision making, only ultra-
is linked to miscarriages. Hyperhomocysteinaemia is a sound examination and blood serum beta-hCG test will help
common finding in patients with the methyl tetrahydrofo- to confirm a diagnosis of a viable pregnancy or a miscarriage.
late reductase (MTHFR) gene mutation151 and is associated hCG is the hormone produced by the trophoblast when
with low folic acid and vitamin B12 levels.130 Therefore, it it implants. hCG can be detected in maternal urine and
is recommended that patients with elevated homocysteine blood soon after implantation. Pregnancy is confirmed if
levels should take high doses of folic acid and vitamin B6 beta-hCG levels are 5 IU/L.152 An hCG level of
and B12.130 150 IU/L on day 15 after IVF embryo transfer is a good
predictor of a viable pregnancy.153 hCG levels between
25 and 50 IU/L 16 days after ovulation may indicate a
Unexplained miscarriages low probability of continuation of the pregnancy
(<35%), whereas levels of >500 IU/L were associated with
Even after patients have been thoroughly investigated, in
high chance of ongoing pregnancy (>95%).154
approximately 50% of cases there are no medically identi-
Serum beta-hCG levels double every 48 h in most, but not
fiable causes for their miscarriages.130
all, healthy pregnancies. A rise of <53% is usually associated
with an abnormal pregnancy.155 Slow rising hCG may indi-
Orthodox conventional medical cate an ectopic pregnancy. A high for gestational age hCG
level may indicate a molar pregnancy. Declining levels of
management of patients presenting hCG suggests a failing pregnancy but may also indicate an
with suspected miscarriage ectopic pregnancy. Depending on the initial levels of
hCG, in a failed pregnancy hCG levels decrease by 21–
Presenting signs and symptoms 35% every 2 days.
Early signs of a miscarriage are similar to the early signs of
an ectopic pregnancy. These include irregular vaginal
bleeding and/or abdominal pain. It is recommended that CLINICAL TIPS
all patients reporting these symptoms should be referred SLOW RISING OF HCG LEVELS AND
to a doctor or an Early Pregnancy Unit (EPU) to exclude ACUPUNCTURE
the possibility of an ectopic pregnancy, which can be fatal
In our experience, acupuncture and moxa on REN4 and REN6
if not managed correctly. Ectopic pregnancy is discussed in
can help in cases where hCG is rising too slowly.
more detail later in this chapter.
315
Acupuncture for IVF and Assisted Reproduction
316
Managing the patient with a complex medical history Chapter | 12 |
Heart, Stomach,165 and Spleen is also associated with Treatment should be done daily until either pregnancy tis-
threatened miscarriages.161 sue is passed or it is no longer deemed safe to wait for a nat-
Pre- and Post-Natal Jing (Essence), Qi, Blood, and other ural miscarriage and a patient is advised to undergo
vital substances influence maternal health, which in turn medical or surgical termination. In some countries, it
influences the embryo’s health. ST36 with moxa is a classi- may be illegal to assist patients in miscarrying pregnancy
cal treatment prescription for the prevention of threatened naturally in a non-hospital setting, even if the pregnancy
miscarriages.166 Therefore, nourishing Qi and Blood is not viable. Acupuncturists must ensure that they follow
enriches the mother, securing the Qi of the embryo or the correct procedure for their country, for example, a writ-
foetus.161 ten permission from a doctor may be needed.
Blood flow enables pregnancy, and the general state of Emotional support is also extremely important during this
Qi and Blood directly affects the functions of the Extraordi- stage. Acupuncture points such as P6, KID27, and YINTANG
nary Vessels and the Uterus.161 Blood Stagnation in the are suitable for most patients. Other points may be chosen
Uterus reduces the circulation of Qi, Blood, and Jing depending on patient’s emotions and background history.
(Essence) to the embryo. This may halt its development
and growth, leading to a miscarriage.165 The treatment
strategy in these cases is to warm and move Blood and reg- TCM management of patients
ulate and circulate Qi of the mother and the embryo.161 with a history of RMs
A weak Uterus (from a varied TCM pathology) can lead
to the opening of the Uterus, which can proceed to a threat- RMs are usually a result of the same syndromes that cause
ened miscarriage.161 spontaneous miscarriages, but much more advanced and
serious. Acupuncture treatment principles are the same,
but stronger Qi and Blood moving points can be used dur-
Red flag ing the preventive phase of treatment. Other generic points
for prevention of RMs are:
Frequent urination in pregnant patients • ST36, KID7, DU20 to tonify and raise Qi and support
Frequent urination is a symptom Kidney Qi Deficiency. the Kidneys
However, it is also a sign of a UTI. Because UTI can cause • SP4 + P6, LI4*, SP6*, SP10 to move Qi and Blood
miscarriages, always check urine in pregnant patients who It may be helpful to use BBT charts in patients with a history of
complain of frequent urination. miscarriages. BBT often drops a day or two before the onset of
bleeding. If such a pattern is observed, an emergency acu-
puncture treatment may help to rescue the pregnancy.
In contrast to Orthodox medicine, TCM places greater
emphasis on prevention of miscarriage. When dealing with
ART patients, it is important to remember that many of When to refer for miscarriage
them are at higher risk of miscarrying, due to pre-existing investigations
medical conditions, extensive use of drugs during ART
treatment, and emotional stress (see Chapter 7 for details Acupuncture can address some causes of RMs, (but not all
on how stress affects fertility). Therefore, close monitoring including, for example, serious genetic or anatomical
of these patients in the first few weeks of pregnancy is essen- abnormalities). Therefore, consideration should be given
tial for prevention of miscarriages. as to whether to refer a patient for advanced conventional
Table 12.3 provides detailed miscarriage TCM diagnostic medical investigations.
information, and Figure 12.5 provides an algorithm for the The decision when to refer patients will depend on the
management of miscarriage patients. patient’s individual set of circumstances and on local
health policies. Investigations are always indicated in cou-
ples with three consecutive miscarriages or one miscarriage
after 12 weeks’ gestation.123
TCM management of inevitable However, there may be instances when investigations
or missed miscarriages could be recommended earlier. For example, if a young
couple miscarry one pregnancy following IVF treatment,
If, following a scan or serial hCG tests, miscarriage is it may be seen as premature to refer them for investigations
classed as inevitable, incomplete, or missed, acupuncture at this point in time, especially as such investigations
treatment may be attempted to help the patient to pass may not be funded. But if a woman is over 40 years old
pregnancy tissue naturally. While treating these patients, and suffers a single spontaneous miscarriage following
they must be monitored very closely in case they develop IVF treatment, it is justifiable to refer her for further
infection or severe bleeding. Some of the acupuncture
points that may be used include: *
These points may need to be avoided if a pregnancy is confirmed. See
• LU7, LI4, SP6, BL32, REN4 (needled toward REN2)164 Chapter 14 for a discussion on forbidden points in pregnancy.
317
318
Chapter | 12 |
319
Threatened miscarriage
(usually presents as vaginal bleeding and/or abdominal pain in pregnancy)
No
- Pale, dilute bleed - Vaginal spotting - Back ache - Bright red bleed - Dark or clotted bleed
- Pale face - Heavy sinking feeling - Dizziness - Red face - Sharp abdominal pain
- May have palpitations in lower abdomen - Frequent urination - Feeling hot - History or trauma
- Tongue: pale - Tongue: pale - Tongue: pale (if Yang - Thirst (e.g. fall), medical
- Pulse: empty, weak - Pulse: fine or weak Xu) peeled whole or - Dark urine procedure on uterus
at rear (if Yin Xu) - Restlessness (e.g. IVF) or pre-
- Pulse: deep, weak - Tongue: red, yellow existing medical
(if Yang Xu); floating coat condition from Blood
and empty or thready - Pulse: rapid Stasis (e.g. fibroids,
(if Yin Xu) endometriosis)
- Tongue: purple
- Pulse: choppy
Key points: Key points: Key points: Key points: Key points:
BL17 (moxa), DU20, ST36, BL23, KID3, REN4 SP10, LI11, KID8 ST29, SP10, P6
ST36, BL20, LIV8 REN12, REN6 (moxa) plus HE5 (if HE-Fire), + REN12 + DU20
LIV2 (if LIV-Fire), KID2
(if Yin Xu)
320
Managing the patient with a complex medical history Chapter | 12 |
321
Acupuncture for IVF and Assisted Reproduction
Management of patients
Case study—cont’d
experiencing anxiety about
miscarrying Point Prescription and Rationale
Tender loving care (TLC) is recommended as an established KID3, KID7 to benefit the embryo, SP3, ST36 supporting
treatment for patients with a history of RMs.151 TLC support Spleen Qi in holding the baby, KID9 to stop uterine
(frequent contact with supporting clinicians, frequent scans, cramping, LIV2 to clear Heat, and Shenmen to calm Shen.
counselling, etc.) has been shown to significantly improve Bleeding stopped 2 h after the treatment. There was no
success of subsequent pregnancy. Regular acupuncture treat- bleeding for the next four days, but Sue felt very tired. Point
ments during the first few weeks of pregnancy could benefit prescription was repeated.
these patients as part of their TLC support. Heavy bleeding and cramping restarted 5 days after the
Patients who have a history of miscarriage(s) benefit second treatment. Sue became distressed. During the
greatly psychologically from frequent ‘reassurance’ scans. emergency acupuncture session her pulse was very thin on
all positions. Point prescription was repeated with the
Develop a working relationship with your local EPU or
addition of LIV8 to boost Liver Blood. Her bleeding stopped
pregnancy scanning facility. Find out what their referral
soon after.
procedures are and refer patients when appropriate.
Two days later Sue passed a large clot. Her hCG levels
Most EPUs are happy to scan patients from 6 weeks’ were 8000 IU/L. Pulse was stronger. Points prescription was
gestation, when they are able to detect a foetal heartbeat. repeated with addition of REN6, DU20 to raise Qi, magnetic
Once patients reach 11–12 weeks’ gestation, some may seeds were placed on Shenmen ear points.
find it helpful to buy a foetal doppler to self-monitor a foe- Two days later ultrasound scan showed one foetal
tal heartbeat. Foetal dopplers are inexpensive to buy. How- heartbeat, but it was slow. Sue’s pulse remained strong, but
ever, while the use of foetal self-monitoring may help some her tongue was still red. Repeated point prescription.
patients, others may find the opposite to be true, especially Bleeding ceased soon after treatment, but restarted with
if they find it difficult to locate the foetal heartbeat. If cramping 5 days later. Her latest hCG results were
patients struggle to find the heartbeat, drinking a glass of 16,000 IU/L (doubled in 7 days, which was too slow a rate of
cold water before attempting to locate the heartbeat can increase for a viable pregnancy). Points prescription was
make it easier. Occasionally, patients confuse their own once again repeated.
heartbeat with their baby’s heartbeat. They need to be Two days later, there was only minor spotting, ultrasound
taught that foetal heartbeat is usually very fast, at least scan showed a faster heartbeat. Sue’s pulse was very
120 beats/min. Some people benefit by being shown slippery. But her tongue was less red. Repeated the same
how to use the monitor correctly. Therefore, advice on point prescription.
doppler foetal self-monitoring should be given with At 9 weeks Sue’s spotting had resolved.
extreme caution, and acupuncturists must use their knowl- Sue had a healthy baby boy delivered by elective
caesarean section at 38 weeks gestation.
edge of each patient when deciding who would benefit
Frequent (every 2–3 daily) acupuncture treatment helped
from using a foetal monitor.
to rescue this pregnancy, even though initially the
prognostic signs were not good (slow foetal heartbeat, slow
rising hCG).
Case study
322
Managing the patient with a complex medical history Chapter | 12 |
Risk factors for developing ectopic pregnancy are:155 Preterm birth and cervical
• History of previous ectopic pregnancy insufficiency
• History of tubal surgery (including tubal sterilization)
The risk of preterm birth (defined as birth before 37 weeks’
• History of sexually transmitted infection or tubal
infection gestation)176 is greater in pregnancies conceived as a result
of ART treatment, independent of maternal age or number
• Pelvic adhesions
of foetuses.82 75–95% of neonatal deaths occur as a result
• Current use of intrauterine device
of preterm births.176 Surviving preterm infants are at
• Smoking
greater risk of severe handicap and long-term health prob-
• Conception following ART
lems.176 Although great efforts are being made by
• In utero exposure to diethylstilboestrol
researchers to identify causes of preterm births, the rates
Early symptoms of ectopic pregnancy include vaginal of preterm births have remained largely unchanged over
bleeding and abdominal pain. Any woman of reproduc- the last 30 years.176
tive age presenting with these symptoms (even if not Risk factors for premature labour include:
known to be pregnant) should be referred for further
investigations.155 • BMI <19.8 kg/m2135,177
In more advanced ectopic pregnancies, a patient will • Vaginal bleeding135
complain of severe cramping, usually to one side, or stab- • Pulmonary disease177
bing pain. She may also show signs of hypovolemic shock, • Hormonal fertility treatment (excluding CC)178
such as dizziness or fainting, her pulse will be rapid, and • BV infection135,177
her blood pressure low.125 These patients need immediate • Pelvic infection135
emergency medical services. • Uterine contractions (regular or irregular)135,177
• Black race135
• Previous preterm birth{135,177
• Cervical length 25 mm{135,177
Red flag
• A positive foetal fibronectin (fFN) test{135,177
Signs of possible ectopic pregnancy that BV accounts for up to 40% of births before 32 weeks’ ges-
require urgent referral to A&E tation.135 It is also associated with early miscarriages in IVF
pregnancies.134 Some experts recommend that one BV
Any woman of reproductive age having vaginal bleeding
with or without:
screen in early pregnancy is sufficient to identify women
® Severe abdominal cramping, possibly to one side, or at risk for preterm birth.136 However, while this will help
stabbing pain to identify women at high risk of preterm birth, it will
® Dizziness or fainting
not help to prevent miscarriages associated with BV,
because they happen very early, usually around the implan-
® Rapid pulse
tation stage or shortly after implantation.134 Therefore, it
® Low blood pressure
might be advisable to screen all women undergoing ART
for BV before ART treatment starts, and perhaps on one
more occasion shortly after embryo transfer, to exclude
the possibility of infection being introduced during the
medical procedures.
Case study Uterine contractions are subjective and may not be
completely reliable as a diagnostic feature. Home Uterine
Ectopic Pregnancy Activity Monitoring may help to monitor contractions
more objectively.176
Kate had recently started acupuncture treatment to prepare
Cervical length measurements taken during transvaginal
her for her second IVF treatment cycle. She emailed me to
find out if the mid-cycle bleeding she was experiencing was ultrasound scans have proved to be highly predictive of pre-
normal. I advised her to do a pregnancy test to exclude a term birth. Shortening of the cervix is known as cervical
possibility of pregnancy. The pregnancy test was positive. incompetence or insufficiency. Opinions vary about what
I then advised her to see her medical practitioner urgently the cervical length should be during various stages of preg-
with a view to being referred for an ultrasound scan to nancy. However, measurement of 25 mm before 32176 to
assess viability of her pregnancy and to exclude the 34179 weeks’ gestation is seen as a reliable significant risk
possibility of ectopic pregnancy. Unfortunately, it took
several days before her scan was arranged and performed.
The scan showed an ectopic pregnancy and substantial {
The last three risk factors are the strongest predictors of preterm
internal bleeding. Surgery was performed on the same day birth.135 The presence of two or more risk factors significantly
and Kate lost one of her fallopian tubes. increases the probability of preterm birth,135 especially if one of the risk
factors is cervical length shorter than 25 mm or a positive fFN test.
323
Acupuncture for IVF and Assisted Reproduction
324
Managing the patient with a complex medical history Chapter | 12 |
325
Acupuncture for IVF and Assisted Reproduction
326
Managing the patient with a complex medical history Chapter | 12 |
327
Acupuncture for IVF and Assisted Reproduction
production.218 Interestingly, in one study, acupuncture was used in research studies include SP6, LI11, YINTANG,
shown to have no effect on TNF-alpha levels in healthy DU20, BL23, REN4, and LU6.221
young individuals, thereby providing further support to
the modulating effect theory.219
Associations of reproductive
Acupuncture and NK cells immunology and TCM
The potential benefit of acupuncture in patients with Other TCM authors have previously identified several syn-
abnormal uNK cell expressions is less clear. We have not dromes that may be involved in immune reproductive fail-
been able to find any research on acupuncture and NK cells ure. These include:
in human or animal studies relating to reproduction. But
• Liver and Kidney Yin Deficiency generating Toxic-
the evidence from non-reproductive patient group studies Heat117
suggests that acupuncture has a modulating effect on the Kidney Jing Deficiency223
•
immune system.218,220,221 Kidney Yin Deficiency224
•
• Kidney Yin (Jing) Deficiency with Empty Fire, Liver Qi
Stagnation, and Blood Deficiency223
INTERESTING FACTS • Damp-Heat and Blood Stasis117,223
IMMUNOMODULATION: COMPARISON OF In our opinion and experience, Blood Stasis is the most com-
ACUPUNCTURE AND IVIG mon syndrome associated with reproductive immunology
issues. Blood Stasis may either lead to infertility or, if concep-
Recent research suggests that acupuncture has an tion occurs, there is a danger of losing the foetus, which can
immunomodulating effect.218,220,221 That means that in happen as early as implantation stage. It is interesting that
patients whose immune system is deficient, acupuncture according to Orthodox medical thinking, most reproductive
boosts it, and in patients whose immune system is immune pathology leads to a blood clotting reaction, pro-
overactive, acupuncture suppresses it. ducing a vascular necrosis of the foetal blood supply.
IVIG, one of the immunotherapy treatments used in
However, in many cases Blood Stasis is a result of other
reproductive immunology, is also immunomodulating in its
underlying pathology, including:
action,222 but it has a number of serious side effects.
More research is necessary to understand exactly how • Kidney Yang Deficiency
acupuncture works and which treatment regimens are • Spleen Qi Deficiency with Dampness
best. But for now it is probably safe to say that acupuncture • Stomach Yin Deficiency Empty-Heat/Fire
should be tried as first-line treatment in patients with • Lung and Spleen Qi Deficiency
suspected or diagnosed reproductive immune issues. • Internal Cold
Once Blood Stasis is formed, it can cause additional comp-
lications associated with reproductive failure. The severity
Acupuncture has been shown to increase the number of level of reproductive failure depends on the extent of pathol-
splenic NK cells.220,221 If acupuncture was also able to ogy. Figure 12.6 outlines the pathogenesis of Blood Stasis
increase the number of uNK cells, then this may possibly in relation to reproductive immunology patients.
create a more favourable environment for implantation. As in Orthodox medicine, reproductive immunology is
The high numbers of uNK cells during the first 12 days of a very new concept in contemporary acupuncture practice.
pregnancy may possibly assist with the formation of the There are very few if any established treatment protocols
blood supply to the baby. It is only when these cells become or diagnostic criteria. The syndromes just listed are
cytotoxic that they can lead to implantation or pregnancy perhaps the more prevalent. However, it is important to
failure.189 NK cells do this by stimulating production of other ‘treat what you find’ when dealing with reproductive
cells (for example, Th1 helper cells such as tumour necrosis immunology cases.
factor, or TNF-alpha cells), which attack the placenta.188 In
turn, TNF-alpha cells can trigger migration into the uterus
of other immune cells (CD3, CD4, and CD8 T cells).188 IMPLICATIONS FOR
ACUPUNCTURISTS: TO REFER OR NOT
Acupuncture points that modulate TO REFER?
the immune system
In their review, Silverio-Lopes and da Mota found that ST36 As already stated, reproductive immunology is a highly
and LI4 (either with manual or EA stimulation) are the controversial area of medicine. Reproductive tests and
most frequently used acupuncture points in acupuncture treatments are not fully proven or accepted, are expensive,
immunomodulation research. Other points that have been and have associated adverse events. Yet, in the authors’
328
Managing the patient with a complex medical history Chapter | 12 |
Qi Deficiency, Damp
Diet, emotion,
EPF, chronic illness • Stagnates Blood overwork, constitution
• Affects circulation • Creates Empty-
BLOOD Liver, Heart,
Kidney • Fails to warm Heat/Fire
STASIS Stomach
Qi and Blood • Fails to nourish
Yang Deficiency Blood Deficiency
and moisten
Kidney Jing,
• Creates Fire Yin Deficiency
• Obstructs Blood • Stagnates Blood
• Congeals Blood • Affects circulation
EPF Emotion
Internal Qi Stagnation
experience, there are patients who seem to succeed with those patients who may potentially benefit from immune
their ART and acupuncture interventions only with the investigations and interventions should be referred once
addition of immune treatments. they are aware of the risks and benefits of these
Ethically, it is very difficult to make recommendations approaches.
if and when we should refer our patients for reproductive Box 12.1 outlines relevant diseases and facts of a
immunology tests and treatments. In our opinion, the patient’s medical history that are associated with repro-
best recommendation that we can make is that acupunc- ductive immune issues. If patients are diagnosed with
turists should be aware of the threat that immunological these diseases and have a history of RIFs or RMs, it
risk factors may pose for a pregnancy to be initially con- may be prudent to recommend reproductive immunology
ceived and then to be kept viable to term. Therefore, assessment.
329
Acupuncture for IVF and Assisted Reproduction
Case study
330
Managing the patient with a complex medical history Chapter | 12 |
Case study—cont’d
® LAD levels of IgG T cells 23.3% and IgG B cells 2.8% ® Blood Stasis: menstrual pain (dull or stabbing), large clots,
(both low) wiry pulse.
® Positive (heterozygote) for the MTHFR C677T mutation ® Full Heat: thirst for cold drinks, sleeping difficulties, can feel
She received a very basic immunotherapy (one intralipid hot in the face especially, very heavy menstrual blood flow,
infusion) with the last two IVF cycles, but they still failed. headaches, constipation, red tongue body.
Josie and her husband were frustrated. She wrote in her
email to me, ‘One of the hardest and most frustrating things Basic Acupuncture Points Prescription
about the whole process is that there are no answers and SP4 + P6, LU7 + KID6, LIV2, LI11, LI4, SP6, SP10, ST36, ST29,
sometimes it doesn’t seem that people are willing to try and ZIGONG
find them. Just keep trying another cycle’. After several months of preparation both with
I referred Josie to a reproductive immunologist with a view immunotherapy and acupuncture, Josie was ready to undergo
of possibly undergoing a more individualized immunotherapy. her sixth cycle of IVF. She conceived and the pregnancy went
In preparation for her next IVF cycle, her reproductive well, although Josie needed regular immunotherapy and
immunologist provided several months of immunotherapy, acupuncture treatment. She had a healthy baby boy.
including TNF-alpha inhibitors (Humira®), LIT, and IVIG. She
Discussion
was also prescribed glucocorticoids and Clexane to be used
during IVF treatment. Combined Orthodox and TCM treatment approaches almost
In the meantime Josie received weekly acupuncture certainly made a difference in this case.
treatments.
TCM Diagnosis
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Chapter | 13 |
The therapeutic relationship in acupuncture
practice
Practitioner and patient interaction is a fundamental attri- Mitchell and Cormack suggest that there are five impor-
bute in the practical application of the philosophy of tant aspects in the development of the therapeutic relation-
Traditional Chinese Medicine (TCM). The therapeutic rela- ship in the practice of complementary medicine: mutuality,
tionship is formed through a series of actions that occur trust, care, challenge and performance, and return to mutu-
during the consultation, treatment, and management of ality.3 Equally so, the evolution of the patient–practitioner
the subfertile patient. Various methods of inquiry involve therapeutic relationship in TCM involves a complexity of
active participation between the patient and practitioner. interactions.
TCM philosophical concepts unify Mind, Body, Emo-
tion, and Spirit, and recognize emotions as a cause and/
or consequence of subfertility. Fertility acupuncturists need
to ensure that the social and psychological consequences
MUTUALITY
of subfertility are identified and are appropriately taken
into consideration in patient management. This can help The initial acupuncture fertility consultation provides the
to put in context a patient’s emotional disposition and foundation for mutuality by means of active participation.
allow appropriate and empathetic management.1 A patient-centred approach to diagnosis4 that is holistic
Fertility acupuncturists can positively influence patients’ in its theoretical foundation gives the patient the opportu-
experience of subfertility and assisted reproductive technol- nity to identify with his or her health and subfertility. The
ogy (ART) treatment. At the same time, acupuncture acupuncturist’s clinical skills such as enquiry, looking, and
supports their health and well-being and positively influ- listening facilitate empathy, validation, and shared
ences Qi, Shen (Spirit), and Jing (Essence). As shown understanding.
in other healthcare contexts, a good therapeutic relation- An integrated approach to the acupuncture consultation
ship psychologically supports a patient’s treatment and combining TCM and Orthodox medical knowledge
management.1,2 This is especially important in fertility- strengthens the subfertility review, identifying other causes,
based acupuncture practice management of subfertility contributing factors, and methods of treatment. This
patients. approach to management and treatment enables the
The synergy of TCM diagnosis, treatment, management, patient to conceptualize his or her health and illness in dif-
and the therapeutic relationship with the practitioner ferent and meaningful ways.
allows the patient to understand more about his or her sub- Patients’ expectations of what they want from acupunc-
fertility and to be potentially more motivated to improve ture are clear. In the authors’ experience, subfertility patients
the factors associated with fertility. It may also help to seek acupuncture treatment to help them conceive, reduce
reduce anxieties and fears about the treatment outcome. their stress levels, and improve their health. Patients often
In this respect, subfertility patients may be comparable to comment that they obtain a sense of control over their
dental patients, who also have concerns and anxieties fertility issues and aspects of their lifestyle through acupunc-
about treatment that, when appropriately addressed in ture treatment. They feel reassured that they are taking
the therapeutic relationship, can be dispersed.1 active steps to optimize their chances of success with IVF.
Discussing and analysing their main complaint highlights patients feel and remain safe and comfortable during the
their individual needs, their specific points of concern, clinical encounter.
and their expectations of what acupuncture treatment and Reassuring a patient that the information he or she
management can provide for them. divulges will be kept confidential is another essential
However, it is necessary for both patients and acupunc- element of trust.3 It is not unusual for the practitioner to treat
turists to appreciate the limits of what acupuncture can both partners or friends of the patient. Patients must feel that
achieve in each individual case. A realistic and an integrated they can share all the nuances of their information with the
approach along with problem solving initiates shared practitioner, without worrying about confidentiality.
understandings and agreement. Mitchell and Cormack pro- Explaining the TCM treatment plan, associated benefits
posed several key steps that demonstrate mutuality within and risks from treatment, and the associated costs enables
the therapeutic relationship that can help complementary the patient to give informed consent to treatment and facil-
practitioners explain to patients how they can help them:3,5 itates trust and compliance.3
• Explain what the treatment may involve, for example, As Mitchel and Cormack have noted, behaving courte-
the way you approach the treatment of fertility. ously and respectfully to patients is a cornerstone of clinical
• Respond helpfully to questions raised by the patient. practice.3 In subfertility patients this is especially important
• Discuss your plan of action to help the patient. when discussing sensitive subjects such as age, interpreta-
• Discuss the patient’s views so he or she can consider the tion of signs and symptoms, test results, treatment progno-
appropriateness of your approach to treatment in the sis, and other parameters.
context of what the patient believes he or she needs and As a fertility acupuncturist, it is very important to under-
wants from the acupuncture treatment. stand the fertility patients’ individual needs and special
requirements and manage a range of emotions (which
can alter very quickly, for example, following a test result)
in order to gain their trust in your abilities and skills.3 As a
normal part of fertility acupuncture practice, you will need
TRUST to support and manage each patient you see in each clinical
encounter, because each one will present with a variety of
Patients place a lot of trust in the decisions that are made on emotions and reactions. Patients’ emotions can be radically
their behalf, for example, in consultants who deem their different from one consultation to the next.
suitability for IVF/ART intervention, the medication they TCM pulse and tongue diagnosis are tools that can facil-
are prescribed, the embryologists who look after their itate both a spoken and unspoken dialogue between prac-
embryos and who make the choices about which embryos titioner and patient, encourage the development of a
are suitable for transfer, and in their acupuncturist’s skills therapeutic relationship, and provide the foundations for
and abilities. trust; methods that are able to positively influence the Shen
Subfertile patients may at times be sensitive and vulner- (Spirit). This is because the patient can observe the
able. Therefore, for them to have a feeling of safety, empa- approach, care, concern, importance, and knowledge
thy2 and trust is very important.3 Patients often feel safer as obtained during the TCM diagnostic process. These factors
a result of seeing practitioners who have the expertise in the also act as treatment quality controls for the patient and
treatment of subfertility and are well versed in understand- practitioner alike. For example, pulse taking involves hold-
ing IVF and ART.4,6 An acupuncturist can achieve the trust ing or touching the patient’s hand. For the acupuncturist,
of a patient by demonstrating excellent knowledge of assessment of the pulse assists in the diagnosis process
reproduction, subfertility, medical tests and investigations, and acts as one of the outcome measures.
and ART treatment. The fertility acupuncturists who can do
this provide reassuring feelings of safety and added security
for the patient.
The practitioner’s sensitivity to the patient’s need for CARE
information during the reproductive medicine consulta-
tion provides the foundation for trust, care, and patient sat- Care for and empathy with the patient is important, as it
isfaction.2 Information provision is important, but it demonstrates a willingness to help the patient at one of
should be delivered according to the individual patient’s the most important times of his or her life – creating a fam-
needs and requirements.4 Some patients like to know ily. Empathy by the clinician shows understanding and
everything about their treatment, medical tests, and proce- acceptance of the patient’s situation.3 An empathic
dures. Other patients would rather not know very much approach helps patients feel more at ease and satisfied.
(which in itself may raise issues of obtaining appropriately One example of this is illustrated in a study of 2146
informed patient consent). patients who rated their satisfaction levels with their first
Boundaries are also important,3 especially so in subfer- consultation, at a private fertility clinic, significantly higher
tile patients. Maintaining appropriate boundaries can help after physicians received training in empathic skills.2
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The therapeutic relationship in acupuncture practice Chapter | 13 |
A range of negative feelings and emotions may be relevant to the patient’s constructs of both IVF and acu-
expressed at different times by patients, for example, hope- puncture and takes into account his or her physical, cogni-
lessness, despair, depression, anxiety, jealousy, or suspi- tive, and psychosocial state.
cion. Patients may worry about the outcome of the At times it is difficult to deal with obstacles (for example,
various aspects of their fertility treatment. A very good ther- from events such as failed IVF cycles, miscarriages,
apeutic relationship helps to manage these concerns and pregnancy-related complications, and stillbirth) that may
emotions, and also reassure and safeguard the patient. have already compromised or may compromise the
The fertility acupuncturist becomes central to the patient’s patient’s current IVF treatment. Managing fertility patients’
support network, with highly sensitive care being a funda- experiences of disappointment of their fertility status can
mental aspect of treatment and management. be challenging. The fertility acupuncturist needs to listen,
Caring for the patient also means caring for yourself.3 acknowledge, accept, and work toward developing a range
Self-reflection is useful, especially after clinical encounters of possible pragmatic solutions, so that they may improve
and the countertransference of emotions that may have the future fertility outcomes of each patient that presents to
affected the practitioner adversely. him or her.
The provision of acupuncture treatment at time-specific Managing successful IVF outcomes against a background
critical times during their IVF cycle is an important aspect of of complications and/or co-morbidities can at times be dif-
care for the patient, and it is expected and valued by ficult for the practitioner, especially if the practitioner lacks
patients. However, there are logistical limitations on your experience in this field of practice. Advice sought from
ability to be always available for treatments. Ensuring that experienced colleagues can be of help. Professional forums
the patient’s acupuncture treatment can still be provided, can sometimes offer assistance.
even if you personally are unavailable to administer it, is Reproductive healthcare is a rapidly evolving field of
very important. So, for example, a smooth transition medicine. Thus, the good fertility acupuncturist needs to
between you and your locum helps to support the patient’s be able to identify and critically review relevant high-
experience and confidence in the locum and you. quality literature. It is imperative that fertility acupunctur-
Manage issues, which may affect the patient or influence ists remain current with advances in the field in order to be
the outcome, professionally. For example, you may need to optimally able to support patients at differing times and
emphasize the value of controlling alcohol intake. Show stages of the patients’ treatment cycle.
you can tolerate patients’ feelings and understand their Continual professional development enhances theo-
concerns and difficulties.1,3 A patient may be annoyed retical knowledge. From this educational process the
and find it difficult to lose weight as suggested by a clini- practitioner derives encouragement and reflective self-
cian, or, alternatively, the patient may be overweight, but confidence, which is mutually beneficial and supportive
thus far may have not received information regarding the to both the patient and practitioner. The practical applica-
benefits of weight loss. Therefore, explaining or reinforcing tion of the most appropriate clinical methodology skills
this to the patient becomes your task. A therapeutic rela- (such as looking and listening), interface bidirectionally
tionship facilitates compliance and professional interven- with the acupuncturist’s theoretical knowledge base and
tion that is accepted and acted upon by the patient. philosophical constructs.
Acknowledge any personal biases or ethical consider- The use of self-reflection tools such as regular audits of
ations that you may have.3 You may have particular opin- practice results can help to provide some objectivity to
ions about reproductive medicine interventions or biases the measurement of a practitioner’s performance and
about a patient’s age, sexual orientation, IVF itself, sex selec- success rates.
tion, or the use of donor sperm or eggs. These personal
biases may influence your treatment choices or the patient’s
experience. Consider whether any such biases limit your
objectivity to truly help the patient. If so, refer to another RETURN TO MUTUALITY
practitioner.
Acknowledge there are limits to what acupuncture treat- Ending treatments provides the means to incorporate rele-
ment can achieve.3 vant advice and the next plan of action.3
Decide on the appropriate time to discharge a patient, for
example, once the treatment objectives have been achieved
and the patient is clinically stable.3 Ensure that the patient
CHALLENGE AND PERFORMANCE is ready and be prepared for this as the patient may have
become dependent and rely on your treatments for support
Summarizing the clinical encounter and data relevant to and feel that you are keeping his or her pregnancy hopes
the challenge and devising treatment principles based upon achievable. Thus the patient may feel a sense of abandon-
an integrated approach is essential. Always maintain a ment or fear that withdrawal of treatment may compromise
respectful and collaborative approach.3,4 Ensure that it is the pregnancy. Provide any relevant resources to help3 and
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Acupuncture for IVF and Assisted Reproduction
reassure the patient. For example, explain and reinforce any loss of control, guilt, low self-esteem, distress, stigmatiza-
lifestyle and dietary advice for pregnancy. You may need to tion, isolation, grief, shame, failure, and resentment.
explain why it is important that the patient continues to be Infertility takes over couples’ lives, with women in partic-
aware of doing everything necessary to stay healthy.3 You ular putting their lives on hold until they conceive.8 Fifty
may need to provide positive reinforcement, so discuss percent of women report that subfertility is the most upset-
and highlight the achievements gained by working ting experience of their lives.9 Subfertility has been shown
together. Give the patient credit for his or her hard work.3 to cause the same distress as suffering a life-threatening dis-
Reassure the patient that he or she can initiate appoint- ease. One study that compared psychological symptoms of
ments for pregnancy care and for prebirth acupuncture subfertile women who were undergoing fertility treatment
treatments or for any additional help, advice, and support found that women had the same depression and anxiety
should it be required. scores as those women who were undergoing treatment
For patients where the treatment has not had a successful for cancer.10
outcome and accepting that ART and acupuncture treat- Men are affected by infertility too. A structured review of
ment have not helped them, analysing the possible reasons 73 studies concluded that both men as well as women expe-
for this outcome and respecting the patient’s decision to rience desire for parenthood in equal measures. In the short
end fertility treatments and move on with his or her life term, infertile men experience infertility specific anxiety
is important and should be done in an appropriate self- and, if their goal is never fulfilled, they experience lasting
reflective manner. sadness.11
Childlessness causes persistent, prolonged anxiety and
depression.8 Failure to overcome subfertility increases
MEASURING THE SUCCESS depressive symptoms.12 Infertility is also linked to a greater
OF ACUPUNCTURE TREATMENT risk of suicide in women.13
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The therapeutic relationship in acupuncture practice Chapter | 13 |
of premature birth, low birth weight; they are also at an • Definition and status of ‘embryo,’ ‘gamete,’ ‘mother,’
increased risk of perinatal death.16 These risks are greater ‘father,’ ‘intended female parent,’ ‘marriage,’ and ‘civil
for multiples, but even singletons are at risk. However, such partnership’
increased perinatal morbidity is also common in subfertile • Prohibition of embryo and genetic material use
women who have not undergone ART, but who experi- • Storage of gametes, embryos
enced delayed conception or had ovulation-induction • Surrogacy arrangements
treatments, albeit that the risks are incrementally • Consents
lower.15,16 Therefore, it would be wrong to attribute these • Cloning
increased risks purely to ART treatment, and it is important • Donor anonymity
to emphasize that the vast majority of ART children are The Human Fertilisation and Embryology Authority is an
healthy.15,17 independent regulatory body that oversees the use of gam-
etes and embryos, as prescribed by the 2008 Act.
In the United States reproductive medicine is one of the
Treatment of much older patients most regulated forms of medicine.24 State regulation,
In 1984 the first baby was born following a successful among other things, covers areas such as licencing; federal
egg donor IVF treatment. The mother of the baby had sec- regulation includes the Fertility Clinic Success Rate and
ondary amenorrhoea and premature ovarian failure.18 The Certification Act and self-regulation guidelines cover ethics
treatment is now widely used in women of advanced repro- and other practice-related matters.24
ductive age who delay parenthood to pursue education Other countries have similar regulatory and self-
or career opportunities or simply do not meet the right regulatory frameworks, based on local laws, religious
partner until later in life. Treatment of older patients has beliefs, and cultural values. Regulation in different coun-
galvanized strong opinions about the ethical aspects of tries varies in areas such as donor anonymity, remunera-
third-party donor treatments, especially in older recipients. tion of donors, number of embryos transferred, freezing
There are also many social and legal concerns. In treating of embryos, treatment funding, and age limits.
older patients, should there, for example, be a cutoff age
for recipients and if so, what should it be?
Medically, with appropriate hormonal support, the uterus Ethical fertility acupuncture practice
is capable of sustaining the pregnancy even in women in
Fertility patients are a highly motivated group of patients
their 60s and 70s. However, these women experience higher
and often will comply with anything they are asked to
rates of complications, such as pregnancy-induced hyperten-
do. But this makes them very vulnerable. Therefore, ART
sion (16–40%), caesarean section (40–76%), and gesta-
and fertility acupuncturists face even more ethical
tional diabetes (20%).18–21
dilemmas than when dealing with other less vulnerable
patient groups. Some of the common ethical issues such
Third-party reproduction as fees, professional boundaries, confidentiality, and conti-
nuity of care are explored in this section.
Campbell explored the issue of the ethical dilemmas poten-
tially being faced by fertility acupuncturists, in particular
donor conception.22 He pointed out that individuals born Fees structure
as a result of donated eggs or sperm may suffer from iden-
Fertility patients require a much higher level of “outside of
tity problems, especially if the biological parents’ identity is
the normal office hours” care. For example, fertility patients
kept hidden. Some countries, for example, the UK, no lon-
regularly send text or email messages that need to be
ger give the right to anonymity for donors. This drives
responded to very quickly to avoid anxiety issues develop-
patients (who wish to keep their infertility treatment a
ing, but also to help ensure their care is optimized. They
secret) to travel to other countries where donor anonymity
often require weekend and evening treatments made avail-
is still the norm. This is referred to as cross-border repro-
able to them at short notice and at great personal life sac-
duction. It remains to be seen if in the UK the removal
rifice on behalf of their acupuncturists.
of anonymity status will result in a further exacerbation
Since assisted reproduction is a rapidly evolving area of
of donor shortage.
medicine, acupuncturists specializing in this field require a
high level of commitment to continual professional devel-
opment. That means that a greater level of investment in
Regulation of ART treatments
time and money is needed in order to keep learning and
Reproductive medicine is highly regulated in different researching about the very latest TCM and Orthodox med-
countries. In the UK the Human Fertilisation and Embry- ical techniques.
ology Act 2008 covers areas of reproductive medicine Therefore, it could be argued that it is only fair that fer-
such as:23 tility acupuncturists charge higher fees for their services and
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Acupuncture for IVF and Assisted Reproduction
Professional boundaries
Sometimes professional boundaries are blurred when deal- Confidentiality
ing with fertility patients. For example, fertility patients It is our responsibility to keep all information confidential,
may need to be provided with a practitioner’s personal con- no matter what condition patients seek treatment for. How-
tact details in order to update their acupuncturist with the ever, when dealing with fertility patients, we are privy to
latest scan details or to arrange an emergency treatment ses- very personal and at times compromising information.
sion. In the authors’ experience, patients do not abuse this. The difficulties can arise when treating both partners or a
However, some acupuncturists may feel uncomfortable donor and the recipient. They may disclose information
about blurring the boundaries. to us that they wish to keep private from each other. Diffi-
It is also very difficult to remain emotionally detached culties may also arise when treating friends. While friends
when dealing with fertility cases, and fertility acupunctur- may be aware of the fact that they are each undergoing IVF,
ists may suffer emotionally with their patients. Therefore, they may not know the full extent of each other’s personal
it is imperative that fertility acupuncturists develop effec- circumstances and we must respect and protect their right
tive coping strategies. to confidentiality. In some cases it may be advisable to
ask a colleague to see one of the patients to ensure total
confidentiality.
Continuity of care
ART patients require time-critical treatments, for example,
on the embryo transfer day. It is the authors’ opinion that Limit of competence
acupuncturists who take on fertility patients and treat them As fertility acupuncturists, our role has evolved. We are
for prolonged periods of time in preparation for IVF must expected by patients to give an opinion on medical aspects
make themselves available or must make appropriate alter- of their treatment. We must do so within the limits of our
native arrangements to ensure that patients are treated professional competence and recognize when the advice we
whenever the treatment is required (including weekends may wish to provide may be outside of our level of quali-
and public holidays). Practitioners should have contin- fications or professional responsibility.
gency plans in place in the event of not being available
to provide treatment due to unexpected illnesses or holiday
arrangements. Cover arrangements could be achieved by
teaming up with another fertility acupuncturist and provid-
Treating patients when the prognosis is
ing cover for each other. very poor or futile
The American Society for Reproductive Medicine defines
‘poor prognosis’ as very low odds of achieving a live birth
Case study (>1% to 5% per cycle) and ‘futility’ as 1% chance of
achieving a live birth.25 The decision whether to treat
Ethical Fertility Acupuncture Practice: patients with a poor or a futile prognosis should be made
Treatment Continuity purely on the grounds of what is in the patient’s best inter-
Sue contacted me to see if I would be willing to treat her on ests and should be done in consultation with the patient. It
the day of her embryo transfer, which was in 2 days’ time on should not be guided by the prospect of financial gain or
for reasons of protecting one’s success rates.25
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The therapeutic relationship in acupuncture practice Chapter | 13 |
Refusing to treat a patient from the very first consultation and continues developing
through the treatment course. The therapeutic relation-
There may be circumstances when we may feel unable to
ship is a fundamental part of the treatment and patient
treat a patient on the basis of our own personal beliefs.
management and can make a significant difference in
For example, we may disagree on religious or other grounds
the patients’ experience and perhaps even an outcome
about women having donor egg babies in their 50s or 60s or
of ART.
about a gay couple raising a child. While we are not obliged
Fertility acupuncturists need to be aware of patients’
to take on a patient, we must be aware of legal ramifications
needs. They also need to be aware of their own feelings,
of refusing to treat a particular subgroup of patients. Special-
especially with respect to emotionally challenging situa-
ist legal advice should be sought in these circumstances.
tions or when the treatment fails. Acupuncturists must real-
ize that the success of acupuncture is not just about helping
patients conceive, but also about enhancing and easing
SUMMARY patients’ experience of ART.
Fertility patients are considered a vulnerable patient
The therapeutic relationship between the practitioner and group. Therefore it is essential that acupuncturists adhere
the patient is extremely important. It begins to develop to strict ethical principles.
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Chapter | 14 |
Aftercare
Fertility acupuncturists play an important role in the weeks Guiding patients in their possible
following a pregnancy test. If the test is negative, we can
future steps
assist patients in their decision-making processes about
all the considerations they may need to take into account Initial disappointment with fertility treatment turns to
when planning for any future attempts at conceiving. If questions being asked. Why did the treatment not work?
the test is positive, we can help patients make a healthy What else can we try? Will the treatment ever work? What
transition from subfertility to pregnancy and parenthood. do we do next? These are difficult questions with no
definitive answers. However, in almost all cases, Assisted
Reproductive Technology (ART) treatment cycles can be
NEGATIVE OUTCOME improved upon, additional tests can be carried out, and
different fertility treatment techniques can be tried.
Providing patients with some feedback on what went well,
On the day of a pregnancy test, silence from a patient often, what could have gone better, and what else they can try in the
but not always, means the result is negative. Patients are next treatment cycle is often well received by patients and
usually very quick to share good news, but it is typically gives them both hope and knowledge. The feedback can be
absolutely heartbreaking for them to share the news about provided formally in the form of a report or less formally,
an unsuccessful outcome. for example, in person or as advice over the phone. Emails
As acupuncturists, we have a responsibility to help these can work well in these circumstances.
patients get through such devastating times. There are In order to provide feedback and any recommendations,
several ways in which we can help. it is helpful to carry out an audit of the patients’ current and
past treatment cycles. Chapter 10 provides information on
what to expect at different stages of the treatment cycle
Immediate aftermath of a and what solutions exist for overcoming the obstacles.
negative test Chapter 12 discusses possible reasons for In Vitro Fertili-
zation (IVF) failure and available solutions and provides
Most patients, in our experience, prefer to grieve in private. an algorithm for auditing implantation failure cases.
However, some may wish to come in for treatment to help Appendix I provides an IVF Audit Tool, which can be used
them in their recovery process. Fertility acupuncturists can when reviewing each case.
help with the immediate emotional and physical trauma.
On an emotional level, these patients often feel sadness,
loss, and sometimes anger and frustration. Emotional When is the right time to stop the
symptoms are frequently made worse by physical symp-
treatment?
toms, such as heavy and often very painful withdrawal
bleeding. Table 14.1 lists some of the acupuncture points There are several reasons why couples may decide to
that may be beneficial in treating patients immediately after discontinue ART treatment, accept that they will never have
a failed treatment cycle. a child, and instead consider the use of alternative options,
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Aftercare Chapter | 14 |
pregnancy-related aches and pains, headaches, anxiety, things that all pregnant women do should be given.
digestive complaints, tiredness, morning sickness, etc. Acupuncture treatment in these patients should include
It is beyond the scope of this book to discuss each ART points to support pregnancy as well as address any psycho-
pregnancy complication. Chapter 12 provided information logical–emotional symptomatology. Supporting patients
on prevention of miscarriages and pregnancy loss. The emotionally and reducing their feeling of being stressed
remainder of this chapter discusses how to support patients during pregnancy is important,16 since maintaining
during the early stages of pregnancy. negative emotions may adversely influence the mother’s
It is recommended that any acupuncturist who works and embryo’s Qi.17
with pregnant patients should have advanced training in
obstetric acupuncture. There are also a number of books
written on the subject of acupuncture in pregnancy, Acupuncture treatment during early
including: pregnancy
• Acupuncture in Pregnancy and Childbirth by Zita West During the first month of pregnancy, the embryo develops
• The Essential Guide to Acupuncture in Pregnancy and via its own transformation and is influenced by the mater-
Childbirth by Debra Betts nal environment (see Chapter 3 for more details on embryo
• Medical Acupuncture in Pregnancy by Ansgar Roemer development).17 A range of factors (for example, parental
• Pregnancy and Gestation in Classical Texts by Elisabeth age, emotions, overexertion) or Traditional Chinese Medi-
Rochat De La Vallee cine (TCM) pathology (for example, Internal dysfunction,
Heat,17 Fire,16 or Cold), may damage the embryo.17
Table 14.2 summarizes TCM understanding of the
Transition from subfertility embryonic development.
Maternal age and/or constitutional weakness16 may
to pregnancy
compromise the embryo’s development due to a reduction
After a positive pregnancy test, many women remain of Qi, Blood, Yin, Yang, and Kidney Jing (Essence). These
worried and anxious about their pregnancy, especially are the same syndromes that are associated with subfertility
those women who have a history of miscarriage(s). (see Chapter 5) and may affect the embryo’s ability to
These patients suffer from the consequences of emo- develop. Therefore assessment and treatment of maternal
tional reactivity, sensitivity, and hypervigilance as a result Qi, Blood, and Jing (Essence) is essential during pregnancy,
of everything they had to go through in order to achieve because it supports the embryo’s development.
a pregnancy. They may experience any number of the There are two main ways to support early pregnancy and
following: reduce the risk of pregnancy loss:
• Inability to relax and enjoy the pregnancy • At initial diagnosis: identification of high-risk
• Fear that something will go wrong syndromes that may be implicated in preclinical
• Compulsion to repeatedly do pregnancy tests and visit pregnancy loss is essential. These potential syndromes
the toilet to check they are not bleeding include Liver Blood Stasis, Spleen Qi Deficiency,
• Feeling like they do not belong to either a pregnant or Kidney Yang Deficiency, Liver and/or Heart Blood
infertile ‘category’, therefore they are not easily able to Deficiency.
access the emotional support they require • The provision of continuous care: Careful monitoring
• Loss of friends they made while undergoing treatment, and the early identification of abnormal
who may still be going through ART treatment manifestations developing in pregnancy enable the
• Problems with the transition from reproductive to acupuncturist to provide timely intervention, thus
obstetric medical care reducing the risk of pathology progressing.
• Desire for more intensive antenatal care (more scans, Pulse reading is one of the ways to assess the viability of
more blood tests, more midwife appointments) pregnancy from a TCM perspective. Pulse readings that
• Guilt, especially if they have a history of miscarriage(s) indicate Qi, Blood, Yin, or Yang Deficiency may identify
or pregnancy losses a high-risk pregnancy. A healthy pregnancy is generally
• Fear of sharing the news with family and friends and represented by a pulse with strength.19
anxiety about questions that they may be asked During the first 3 months of pregnancy, the embryo
• Worry that they are too old to be parents, if conception develops into a foetus and transforms under a range of
took place later in life maternal influences, particularly Liver Blood, Jing
• Bonding issues (Essence), Shen (Spirit), and the Mind.
• ‘Putting up’ with negative pregnancy symptoms and Several acupuncture points have been suggested as ‘for-
not complaining, for fear of being seen as ungrateful bidden’ in pregnancy, including LI4,20 SP6,21 GB21,22
Patients should be reassured that to experience any of these and BL60.23 However, some authors argue that there is
feelings is not unusual. Encouragement to do the ‘normal’ no physiological (medical) basis for this rule.24,25
349
Acupuncture for IVF and Assisted Reproduction
350
Aftercare Chapter | 14 |
Studies appear to show that there are no adverse conse- It is important to note that some women prefer to stop
quences to the pregnancy from needling of the ‘forbidden’ seeing their fertility acupuncturist as soon as they are preg-
points in pregnant rats.26,27 To the contrary, needling LI428 nant. For some women the maintenance of acupuncture at
and SP629 has been shown to reduce uterine contractions, this stage is psychologically discomforting. Acupuncture
which are associated with negative pregnancy outcomes. treatments act as a reminder to these patients of their infer-
Ultimately, each acupuncturist must make his or her tility and they are keen to put their infertility history behind
own decision about whether to use these points in preg- them and move on with their lives. However, such patients
nant patients. For example, if a patient has a history of are a minority. Most women feel attached to their acupunc-
recurrent miscarriages due to Blood Stasis, SP6 may help turist and develop a real strong sense of bond and trust.
to treat the underlying pathology and prevent another mis-
carriage. This example illustrates that patient’s constitution
and underlying pathology should also be taken into
account when deciding on the points prescription. ACUPUNCTURIST’S SELF-CARE:
SAYING GOODBYE TO PATIENTS
When to discharge pregnant patients
As a result of the complex nature of their reproductive health,
For the majority of patients, acupuncture should be contin- fertility patients are often treated over a long period of time.
ued until at least 12 weeks’ gestation. For high-risk preg- We get to know these patients very intimately and share in
nancies, it may be prudent to continue with acupuncture their extreme lows and highs. However, there comes a time
treatment until the baby is delivered. Table 14.3 provides when we need to say goodbye. In many cases, it is because they
detailed treatment frequency recommendations. have conceived or have had their baby. Sometimes, it is
However, these are not prescriptive. They are proposed because there is nothing else we can do to help them. It is
guidelines that should be adapted to the individual patient. surprising how emotional the discharge appointment can be.
351
Acupuncture for IVF and Assisted Reproduction
As fertility acupuncturists, we can also feel a range of dif- patients to decide on what their next course of action
ferent emotions, including sadness, happiness, loss, or should be, whether it be to try more ART and other
even grief. In cases where we were unable to help our treatments or make a decision to move on by accepting
patients, we might feel frustration and guilt, and we may their infertility.
feel we have failed. Sometimes these feelings can get so When a course of ART treatment succeeds in creating a
strong that we may need to share them with a colleague. pregnancy, fertility acupuncturists must be cognisant
However, all of these feelings are normal and a reflection that things can and sometimes do go wrong. Fertility
and a reminder of how much we care for our patients acupuncturists should carry out a risk assessment when
and how emotionally charged this field of medicine can planning to continue with any further acupuncture
be. The feeling of elation and jubilation when we ‘crack’ treatment or when deciding to discharge their patient.
a challenging case and when we get to share in our patients’ The risk of some pregnancy complications can be min-
excitement and joy when they conceive and when they go imized with acupuncture, and where possible, an
onto have a baby is really special. Then the desire sets in to attempt should be made to reduce the possibility of
repeat it all over again with other patients. complications.
For those patients who conceive, acupuncture treat-
ment should be continued during the first trimester
SUMMARY and in some cases throughout pregnancy to reduce the
risks of complications that may ultimately threaten
Although many of our patients succeed in having a baby, the viability of the pregnancy and the delivery of a
some do not. Fertility acupuncturists can help these healthy baby or the wellbeing of the mother.
REFERENCES
1. Jarrett LS. The Liver. In: The 7. Domar AD. Impact of psychological pregnancies after IVF/ICSI. Hum
clinical practice of Chinese factors on dropout rates in insured Reprod 2003;18:1720–3.
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Path Press; 2003. p. 549–70 2004;81:271–3. Reproductive outcomes after in-vitro
[chapter 31]. 8. McDowell S, Murray A. Barriers to fertilization. Curr Opin Obstet
2. Deadman P, Al-Khafaji M, Baker K. continuing in vitro fertilisation – why Gynecol 2007;19:113–9.
The governing vessel. In: A manual of do patients exit fertility treatment? 15. Allen VM, Wilson RD, Cheung A,
acupuncture. England: Journal of Aust N Z J Obstet Gynaecol et al. Pregnancy outcomes after
Chinese Medicine Publications; 2011;51:84–90. assisted reproductive technology.
1998. p. 527–62. 9. Olivius C, Friden B, Borg G, et al. J Obstet Gynaecol Can
3. Jarrett LS. Kidney. In: The clinical Why do couples discontinue 2006;28:220–50.
practice of Chinese medicine. in vitro fertilization treatment? A 16. Wu YL. An uncertain harvest,
Stockbridge, MA: Spirit Path Press; cohort study. Fertil Steril pregnancy and miscarriage. In:
2003. p. 427–59 [chapter 27]. 2004;81:258–61. Reproducing women: medicine,
4. Lu HC. Verbal questions. In: A 10. Domar AD, Smith K, Conboy L, et al. metaphor, and childbirth in late
complete translation of the Yellow A prospective investigation into the imperial China. Berkeley: University
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College of Traditional Chinese 11. Reichman DE, Chung P, Meyer L, Yào Fang. Essential prescriptions
Medicine; 2004. p. 481–7, et al. Consecutive GnRH – antagonist worth a thousand in gold for
Section three: Spiritual pivot [Ling IVF cycles: does the elapsed time every emergency. 3 Volumes on
Shu] [chapter 28]. interval between successive gynecology, vol. 3. Portland:
5. Verit FF, Verit A. How effective is treatments affect outcomes? Fertil The Chinese Medicine Database;
in vitro fertilization, and how can it Steril 2013;99:1277–82. 2007. p. 232–362 [chapter 3].
be improved? Fertil Steril 12. Blok L, Kremer J. In vitro fertilisation 18. Sun Si-Miao. Translation. In:
2011;95:1677–83. and intracytoplasmic sperm injection. Wilms S, translator. Bèi Jı́ Qian Jin
6. Lande Y, Seidman DS, Maman E, In: de Haan N, Spelt M, Gobel R, Yào Fang. Essential prescriptions
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free assisted reproduction textbook for paramedics. Amsterdam: emergency. 3 Volumes on
treatment have a very high chance Elsevier Gezondheidszorg; 2010. gynecology, vol. 2. Portland: The
of achieving a live birth within p. 105–26 [chapter 8]. Chinese Medicine Database; 2007.
4 years. Fertil Steril 13. Tummers P. Risk of spontaneous p. 52–216 [chapter 2].
2011;95:568–72. abortion in singleton and twin
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19. Rochat de la Vallee E. Pulses in 23. Deadman P, Al-Khafaji M, Baker K. 27. Guerreiro da Silva AV,
pregnancy. In: Root C, editor. The Bladder channel. In: A manual of Nakamura MU, Guerreiro da Silva JB,
Pregnancy and gestation: in Chinese acupuncture. England: Journal of et al. Could acupuncture at the so-
classical texts. Norfolk: Monkey Chinese Medicine Publications; called forbidden points be harmful
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20. Deadman P, Al-Khafaji M, Baker K. 24. da Silva AV, Nakamura MU, Acupunct Med 2013;31:202–6.
The Large Intestine channel. In: da Silva JB. ‘Forbidden points’ in Available from: http://dx.doi.org/
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Journal of Chinese Medicine Publi- Forsch Komplementmed acupuncture. Am J Chin Med
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353
Appendix |I|
Templates
Personal details
Tel (H)
Tel (M)
Tel (W)
Email
Family doctor's name and clinic contact details Fertility doctor's name and clinic
contact details (if relevant)
Occupation Hobbies
Presentation
_______ months/years
_______ actual chances of conception
356
Templates Appendix |I|
Notes
Menstrual cycle (see Chapters 2, 5 and 8)
Age at menarche
Menses Days
–3 –2 –1 1 2 3 4 5 6 7
Colour
Flow:
spotting (S)/heavy (H)/
normal (N)/light (L)
Consistency
Other remarks
Premenstrual When
symptoms Breast tenderness
Mood alteration
Bloating
Bowel habits
Headaches
Back pain
Other
Vaginal bleeding
outside of period
Continued
357
Acupuncture for IVF and Assisted Reproduction
Notes
Manifestations (see Chapter 5)
Temperature
Sweating
Thirst, drink preferences
Mouth, throat
Digestive problems
Bowels
Urination
Sleep, dreaming
Chest pain/palpitations
Lungs and breathing
Headaches
Dizziness
Memory, concentration
Musculoskeletal pain
Energy levels
Skin, hair
Ears and hearing
Eyes and eyesight
Vaginal discharges
Emotional disposition
Constitution
Notes
Observations (see Chapter 5)
Jing-Shen
(overall complexion,
eyes)
Spirit/emotion/
colour/odour
Pulse L R
Tongue
Abdominal palpation
358
Templates Appendix |I|
Notes
Past medical history (see Chapter 5)
STDs
Pelvic inflammatory
disease or infections
Pelvic surgery
(e.g. appendicitis,
ovarian cysts)
Cervical conization
Cancer
Other
Past pregnancies
and outcome of each
(in this or previous
relationship(s))
Notes
Family medical history (see Chapter 5)
Major illnesses
(e.g., thyroid disease,
diabetes, PCOS, early
onset menopause, high
blood pressure, etc.)
Reproductive health
(miscarriages, infertility,
twins delivery, etc.)
Continued
359
Acupuncture for IVF and Assisted Reproduction
360
Templates Appendix |I|
Personal details
Tel (H)
Tel (M)
Tel (W)
Email
Family doctor's name and clinic ART doctor's name and clinic
contact details contact details (if relevant)
Occupation Hobbies
Presentation
Length of subfertility
_______ months/years
_______ actual chances of conception
361
Acupuncture for IVF and Assisted Reproduction
Notes
Manifestations (see Chapter 5)
Vasectomy
Temperature
Sweating
Thirst, drink preference
Mouth, throat
Digestive problems
Bowels
Urination
Sleep, dreaming
Chest pain/palpitations
Lungs and breathing
Headaches
Dizziness
Memory, concentration
Musculoskeletal pain
Energy levels
Skin, hair
Ears and hearing
Eyes and eyesight
Emotional disposition
Breast discharges
Constitution
Notes
Observations (see Chapter 5)
Jing-Shen
(overall complexion,
eyes)
Spirit/emotion/
colour/odour
Pulse L R
Tongue
362
Templates Appendix |I|
Notes
Past medical history (see Chapter 5)
STDs
Testicular trauma
or torsion
Surgery (e.g., hernia,
orchidopexy, vasectomy)
Undescended testis
Mumps
Cancer
Other
Past pregnancies
and outcome of each
(in this or previous
relationship(s))
Notes
Family medical history (see Chapter 5)
Major illnesses
(e.g., thyroid disease,
blood pressure,
diabetes, etc.)
Reproductive health
(miscarriages, infertility,
twins delivery, etc.)
Continued
363
Acupuncture for IVF and Assisted Reproduction
364
Templates Appendix |I|
Notes
Initial test Retest (see Chapters 4 and 12)
Ovarian reserve
Ovulation
Progesterone Date ____________________ Date ____________________
____ nmol/L / ng/mL ____ nmol/L / ng/mL
day____of____days cycle day____of____days cycle
Utero-tubal investigations
Ovaries Date ____________________ Date ____________________
assessment Details Details
365
Acupuncture for IVF and Assisted Reproduction
Thrombophilia screen
Inherited Protein C Thrombomodulin gene variants
thrombophilia Protein S PAl-1 activity levels
Antithrombin III PAl-1 4G/4G polymorphism
Factor V Leiden MTHFR C677T
Prothrombin Gene Mutation (20210A) Factor evaluation (VII, VIII, IX, XI)
Protein Z Platelet count
Homocysteine Other
Other FV mutations
Immune screen
Date
Th1:Th2
IgG T
IgG B
HLA-Dq alpha
Other immune
investigations
366
Templates Appendix |I|
Infection screen
Infection screen Date ___________________ Date ___________________
Details Details
Genetic tests
Karyotyping, fragile Date ___________________
_
X syndrome, etc. Details
Other
Rubella status Date __________________
__ Date ___________________
Details Details
367
Acupuncture for IVF and Assisted Reproduction
Notes
Initial test Retest (see Chapters 4 and 12)
Semen analysis
Date ____________________ Date ____________________
Days of abstinence ________________________ ________________________
Exposure to
heat/fever yes/no yes/no
Influencing lifestyle
factors ________________________ ________________________
Semen volume _________mL _________mL
Sperm concentration _________106 per mL _________106 per mL
Total sperm number _________106 per ejaculate _________106 per ejaculate
Total motility
(PR+NP) _________% _________%
Progressive
motility (PR) _________% _________%
Vitality
(live spermatozoa) _________% _________%
Sperm morphology
(normal forms) _________% _________%
pH _________ _________
Peroxidase-positive
leukocytes _________106 per mL _________106 per mL
MAR test
(motile spermatozoa
with bound particles) _________% _________%
Immunobead test
(motile spermatozoa
with bound beads) _________% _________%
Seminal zinc _________µmol/ejaculate _________µmol/ejaculate
Seminal fructose _________µmol/ejaculate _________µmol/ejaculate
Seminal
neutral glucosidase _________mU/ejaculate _________mU/ejaculate
Semen leukocytes Round cells_____mil/mL Round cells_____mil/mL
White blood cells_____mil/mL White blood cells_____mil/mL
DNA fragmentation
Date ___________________ Date ___________________
SCSA _________% _________%
TUNEL _________% _________%
COMET _________% _________%
MSOME
Findings Date ___________________ Date ___________________
Details Details
Endocrine investigations
Date ___________________ Date ___________________
FSH low/normal/high low/normal/high
LH low/normal/high low/normal/high
Testosterone low/normal low/normal
Prolactin normal/high normal/high
368
Templates Appendix |I|
Ultrasound
Transrectal Date ___________________
ultrasound (TRUS):
Dilated seminal
vesicles yes/no
Dilated ejaculatory
ducts yes/no
Midline cystic
prostatic structures yes/no
Infection screen
Infection screen Date ___________________ Date ___________________
Details Details
Genetic tests
Karyotyping Date ___________________
Cystic fibrosis Details
gene mutation
Y-chromosome
analysis
Other
Anti-sperm Date _______________ yes/no
antibodies (ASA)
369
Acupuncture for IVF and Assisted Reproduction
Notes
Initial details Review (see Chapter 7)
Date
Weight ______kg ______kg
BMI ______kg/m2 ______kg/m2
Environmental
toxins exposure
Occupational
risk factors
Medication
(prescribed and over
the counter)
Supplements
(details and dose)
370
Templates Appendix |I|
Diet:
Special diet followed (e.g.,
vegan, vegetarian, etc.)
Snack
Lunch
Snack
Dinner
Snack
Cravings
Dislikes
371
Acupuncture for IVF and Assisted Reproduction
Coitus
(For couples where natural conception is possible)
Patient's name (female):__________________________________________DOB:________________
Patient's name (male):____________________________________________DOB:________________
Notes
Initial details Review
(see Chapter 7)
Date
Fertile window estimation Shortest cycle length: Shortest cycle length:
____ – 14 – 5 =____(a) ____ – 14 – 5 =____(a)
Fertile mucus:
when __________day(s) of cycle __________day(s) of cycle
quantity scanty/profuse scanty/profuse
Intercourse frequency:
During fertile window ____________________ ____________________
Outside of fertile window ____________________ ____________________
Libido:
Male partner ______out of 10 ______out of 10
Female partner ______out of 10 ______out of 10
Arousal, enjoyment
Notes
Treatment cycle 1 Treatment cycle 2
(see Chapters 4 and 12)
Date treatment
cycle started
Stress levels,
emotional imbalances
Lifestyle modifications made in preparation for ART treatment and how long for
What modifications
were made?
373
Acupuncture for IVF and Assisted Reproduction
Pretreatment phase up to 4 weeks before treatment cycle (downregulation, contraceptive pill, etc.)
Medication, dose,
length of administration
Other medication
(e.g. aspirin, clexane,
steroids, intralipids,
thyroid medication, etc.)
374
Templates Appendix |I|
Follicles: Follicles:
Left Right Left Right
1_______mm 1_______mm 1_______mm 1_______mm
2_______mm 2_______mm 2_______mm 2_______mm
3_______mm 3_______mm 3_______mm 3_______mm
4_______mm 4_______mm 4_______mm 4_______mm
5_______mm 5_______mm 5_______mm 5_______mm
6_______mm 6_______mm 6_______mm 6_______mm
7_______mm 7_______mm 7_______mm 7_______mm
8_______mm 8_______mm 8_______mm 8_______mm
9_______mm 9_______mm 9_______mm 9_______mm
10_______mm 10_______mm 10_______mm 10_______mm
Hyperstimulation (OHSS)
symptoms (bloating, diarrhoea,
constipation, reduced urination,
breathing difficulties, weight gain)
Continued
375
Acupuncture for IVF and Assisted Reproduction
Was embryoscope/
EEVA used?
Results of embryo
genetic diagnosis, if done
(e.g. CGH, PGD, etc.)
Embryo transfer
Embryos transferred Grade____________day_____ Grade____________day_____
Grade____________day_____ Grade____________day_____
Grade____________day_____ Grade____________day_____
Early pregnancy
symptoms
Poor prognostic
symptoms (bleeding,
abdominal cramping, etc.)
376
Templates Appendix |I|
Threatened miscarriage
symptoms (bleeding,
abdominal or back
cramping)
Acupuncture treatment
Pregnancy outcome:
Live birth ________weeks' gestation ________weeks' gestation
377
Appendix | II |
Basal body temperature (BBT) chart template
and instructions
Intercourse
BASAL BODY TEMPERATURE (BBT) • It would also be helpful if you could mark the days
TEMPLATE when you have intercourse.
Cervical Fluid
Basal Body Temperature (BBT)
Charting Instructions • Observe what kind of vaginal secretions you have and
log at the end of the day. Use the relevant keys provided
Taking the Temperature at the bottom of the chart. For example, if you have
fertile mucus, which looks like egg white and stretches
• Use a special fertility thermometer (in C). It should without breaking, enter E on the relevant day, for blood
have two decimal places and is more sensitive than a
enter B, if you have no secretions, enter D and if your
standard thermometer.
secretions are moist or creamy, enter C.
• Keep the thermometer next to your bed ready to be
used in the morning.
• Your temperature should be taken at the same time Ovulation Test Results
every morning after at least three consecutive hours of • If you use an ovulation detection kit, mark the days on
sleep and immediately when you wake up, before you the chart when you get positive or peak reading on your
get out of bed or do anything else (for example before ovulation test.
you go to the toilet, feed a cat etc).
• Most people prefer to take their temperature orally. But Other Notes
it can also be taken vaginally, rectally or under your
arm. Use the same method throughout. • The following factors are known to affect the
temperature. Please make a note in the “special notes”
section when any of these are applicable:
n If you have alcohol the night before (even small
amounts)
Recording the Temperature n If you have an illness (for example cold, flu or other
• Start taking your temperature on day one of infections)
your menstrual bleed. If you have spotting n If you have bad night’s sleep (especially if you slept
before proper bleeding starts, wait until the proper for less than 3 hours before taking temperature)
bleed and this will be classed as your menstrual n If you had to take medication (especially
cycle day 1. temperature lowering medication, such as
• Record on the chart the date and the time on the paracetamol or ibuprofen)
relevant menstrual cycle day. n If the bedroom is unusually hot or cold
• Put a cross on the square with the temperature nearest n If you feel stressed
to the one your thermometer is showing. n If you travel, especially air travel
Date
Time
Waking basal temp. 37.60 37.60 37.60 37.60 37.60 37.60 37.60 37.60 37.60 37.60 37.60 37.60 37.60 37.60 37.60 37.60 37.60 37.60 37.60
37.55 37.55 37.55 37.55 37.55 37.55 37.55 37.55 37.55 37.55 37.55 37.55 37.55 37.55 37.55 37.55 37.55 37.55 37.55
37.50 37.50 37.50 37.50 37.50 37.50 37.50 37.50 37.50 37.50 37.50 37.50 37.50 37.50 37.50 37.50 37.50 37.50 37.50
37.45 37.45 37.45 37.45 37.45 37.45 37.45 37.45 37.45 37.45 37.45 37.45 37.45 37.45 37.45 37.45 37.45 37.45 37.45
37.40 37.40 37.40 37.40 37.40 37.40 37.40 37.40 37.40 37.40 37.40 37.40 37.40 37.40 37.40 37.40 37.40 37.40 37.40
37.35 37.35 37.35 37.35 37.35 37.35 37.35 37.35 37.35 37.35 37.35 37.35 37.35 37.35 37.35 37.35 37.35 37.35 37.35
37.30 37.30 37.30 37.30 37.30 37.30 37.30 37.30 37.30 37.30 37.30 37.30 37.30 37.30 37.30 37.30 37.30 37.30 37.30
37.25 37.25 37.25 37.25 37.25 37.25 37.25 37.25 37.25 37.25 37.25 37.25 37.25 37.25 37.25 37.25 37.25 37.25 37.25
37.20 37.20 37.20 37.20 37.20 37.20 37.20 37.20 37.20 37.20 37.20 37.20 37.20 37.20 37.20 37.20 37.20 37.20 37.20
37.15 37.15 37.15 37.15 37.15 37.15 37.15 37.15 37.15 37.15 37.15 37.15 37.15 37.15 37.15 37.15 37.15 37.15 37.15
37.10 37.10 37.10 37.10 37.10 37.10 37.10 37.10 37.10 37.10 37.10 37.10 37.10 37.10 37.10 37.10 37.10 37.10 37.10
37.05 37.05 37.05 37.05 37.05 37.05 37.05 37.05 37.05 37.05 37.05 37.05 37.05 37.05 37.05 37.05 37.05 37.05 37.05
37.00 37.00 37.00 37.00 37.00 37.00 37.00 37.00 37.00 37.00 37.00 37.00 37.00 37.00 37.00 37.00 37.00 37.00 37.00
36.95 36.95 36.95 36.95 36.95 36.95 36.95 36.95 36.95 36.95 36.95 36.95 36.95 36.95 36.95 36.95 36.95 36.95 36.95
36.90 36.90 36.90 36.90 36.90 36.90 36.90 36.90 36.90 36.90 36.90 36.90 36.90 36.90 36.90 36.90 36.90 36.90 36.90
36.85 36.85 36.85 36.85 36.85 36.85 36.85 36.85 36.85 36.85 36.85 36.85 36.85 36.85 36.85 36.85 36.85 36.85 36.85
36.80 36.80 36.80 36.80 36.80 36.80 36.80 36.80 36.80 36.80 36.80 36.80 36.80 36.80 36.80 36.80 36.80 36.80 36.80
36.75 36.75 36.75 36.75 36.75 36.75 36.75 36.75 36.75 36.75 36.75 36.75 36.75 36.75 36.75 36.75 36.75 36.75 36.75
36.70 36.70 36.70 36.70 36.70 36.70 36.70 36.70 36.70 36.70 36.70 36.70 36.70 36.70 36.70 36.70 36.70 36.70 36.70
36.65 36.65 36.65 36.65 36.65 36.65 36.65 36.65 36.65 36.65 36.65 36.65 36.65 36.65 36.65 36.65 36.65 36.65 36.65
36.60 36.60 36.60 36.60 36.60 36.60 36.60 36.60 36.60 36.60 36.60 36.60 36.60 36.60 36.60 36.60 36.60 36.60 36.60
36.55 36.55 36.55 36.55 36.55 36.55 36.55 36.55 36.55 36.55 36.55 36.55 36.55 36.55 36.55 36.55 36.55 36.55 36.55
36.50 36.50 36.50 36.50 36.50 36.50 36.50 36.50 36.50 36.50 36.50 36.50 36.50 36.50 36.50 36.50 36.50 36.50 36.50
36.45 36.45 36.45 36.45 36.45 36.45 36.45 36.45 36.45 36.45 36.45 36.45 36.45 36.45 36.45 36.45 36.45 36.45 36.45
36.40 36.40 36.40 36.40 36.40 36.40 36.40 36.40 36.40 36.40 36.40 36.40 36.40 36.40 36.40 36.40 36.40 36.40 36.40
36.35 36.35 36.35 36.35 36.35 36.35 36.35 36.35 36.35 36.35 36.35 36.35 36.35 36.35 36.35 36.35 36.35 36.35 36.35
36.30 36.30 36.30 36.30 36.30 36.30 36.30 36.30 36.30 36.30 36.30 36.30 36.30 36.30 36.30 36.30 36.30 36.30 36.30
36.25 36.25 36.25 36.25 36.25 36.25 36.25 36.25 36.25 36.25 36.25 36.25 36.25 36.25 36.25 36.25 36.25 36.25 36.25
36.20 36.20 36.20 36.20 36.20 36.20 36.20 36.20 36.20 36.20 36.20 36.20 36.20 36.20 36.20 36.20 36.20 36.20 36.20
36.15 36.15 36.15 36.15 36.15 36.15 36.15 36.15 36.15 36.15 36.15 36.15 36.15 36.15 36.15 36.15 36.15 36.15 36.15
36.10 36.10 36.10 36.10 36.10 36.10 36.10 36.10 36.10 36.10 36.10 36.10 36.10 36.10 36.10 36.10 36.10 36.10 36.10
36.05 36.05 36.05 36.05 36.05 36.05 36.05 36.05 36.05 36.05 36.05 36.05 36.05 36.05 36.05 36.05 36.05 36.05 36.05
36.00 36.00 36.00 36.00 36.00 36.00 36.00 36.00 36.00 36.00 36.00 36.00 36.00 36.00 36.00 36.00 36.00 36.00 36.00
35.95 35.95 35.95 35.95 35.95 35.95 35.95 35.95 35.95 35.95 35.95 35.95 35.95 35.95 35.95 35.95 35.95 35.95 35.95
35.90 35.90 35.90 35.90 35.90 35.90 35.90 35.90 35.90 35.90 35.90 35.90 35.90 35.90 35.90 35.90 35.90 35.90 35.90
35.85 35.85 35.85 35.85 35.85 35.85 35.85 35.85 35.85 35.85 35.85 35.85 35.85 35.85 35.85 35.85 35.85 35.85 35.85
35.80 35.80 35.80 35.80 35.80 35.80 35.80 35.80 35.80 35.80 35.80 35.80 35.80 35.80 35.80 35.80 35.80 35.80 35.80
35.75 35.75 35.75 35.75 35.75 35.75 35.75 35.75 35.75 35.75 35.75 35.75 35.75 35.75 35.75 35.75 35.75 35.75 35.75
35.70 35.70 35.70 35.70 35.70 35.70 35.70 35.70 35.70 35.70 35.70 35.70 35.70 35.70 35.70 35.70 35.70 35.70 35.70
Cycle day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
Intercourse
Cervical fluid*
Ovulation test
result
Pregnancy test
result
Other notes:
Poor sleep
Alcohol
Illness
Additional
information:
380
20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40
37.60 37.60 37.60 37.60 37.60 37.60 37.60 37.60 37.60 37.60 37.60 37.60 37.60 37.60 37.60 37.60 37.60 37.60 37.60 37.60 37.60
37.55 37.55 37.55 37.55 37.55 37.55 37.55 37.55 37.55 37.55 37.55 37.55 37.55 37.55 37.55 37.55 37.55 37.55 37.55 37.55 37.55
37.50 37.50 37.50 37.50 37.50 37.50 37.50 37.50 37.50 37.50 37.50 37.50 37.50 37.50 37.50 37.50 37.50 37.50 37.50 37.50 37.50
37.45 37.45 37.45 37.45 37.45 37.45 37.45 37.45 37.45 37.45 37.45 37.45 37.45 37.45 37.45 37.45 37.45 37.45 37.45 37.45 37.45
37.40 37.40 37.40 37.40 37.40 37.40 37.40 37.40 37.40 37.40 37.40 37.40 37.40 37.40 37.40 37.40 37.40 37.40 37.40 37.40 37.40
37.35 37.35 37.35 37.35 37.35 37.35 37.35 37.35 37.35 37.35 37.35 37.35 37.35 37.35 37.35 37.35 37.35 37.35 37.35 37.35 37.35
37.30 37.30 37.30 37.30 37.30 37.30 37.30 37.30 37.30 37.30 37.30 37.30 37.30 37.30 37.30 37.30 37.30 37.30 37.30 37.30 37.30
37.25 37.25 37.25 37.25 37.25 37.25 37.25 37.25 37.25 37.25 37.25 37.25 37.25 37.25 37.25 37.25 37.25 37.25 37.25 37.25 37.25
37.20 37.20 37.20 37.20 37.20 37.20 37.20 37.20 37.20 37.20 37.20 37.20 37.20 37.20 37.20 37.20 37.20 37.20 37.20 37.20 37.20
37.15 37.15 37.15 37.15 37.15 37.15 37.15 37.15 37.15 37.15 37.15 37.15 37.15 37.15 37.15 37.15 37.15 37.15 37.15 37.15 37.15
37.10 37.10 37.10 37.10 37.10 37.10 37.10 37.10 37.10 37.10 37.10 37.10 37.10 37.10 37.10 37.10 37.10 37.10 37.10 37.10 37.10
37.05 37.05 37.05 37.05 37.05 37.05 37.05 37.05 37.05 37.05 37.05 37.05 37.05 37.05 37.05 37.05 37.05 37.05 37.05 37.05 37.05
37.00 37.00 37.00 37.00 37.00 37.00 37.00 37.00 37.00 37.00 37.00 37.00 37.00 37.00 37.00 37.00 37.00 37.00 37.00 37.00 37.00
36.95 36.95 36.95 36.95 36.95 36.95 36.95 36.95 36.95 36.95 36.95 36.95 36.95 36.95 36.95 36.95 36.95 36.95 36.95 36.95 36.95
36.90 36.90 36.90 36.90 36.90 36.90 36.90 36.90 36.90 36.90 36.90 36.90 36.90 36.90 36.90 36.90 36.90 36.90 36.90 36.90 36.90
36.85 36.85 36.85 36.85 36.85 36.85 36.85 36.85 36.85 36.85 36.85 36.85 36.85 36.85 36.85 36.85 36.85 36.85 36.85 36.85 36.85
36.80 36.80 36.80 36.80 36.80 36.80 36.80 36.80 36.80 36.80 36.80 36.80 36.80 36.80 36.80 36.80 36.80 36.80 36.80 36.80 36.80
36.75 36.75 36.75 36.75 36.75 36.75 36.75 36.75 36.75 36.75 36.75 36.75 36.75 36.75 36.75 36.75 36.75 36.75 36.75 36.75 36.75
36.70 36.70 36.70 36.70 36.70 36.70 36.70 36.70 36.70 36.70 36.70 36.70 36.70 36.70 36.70 36.70 36.70 36.70 36.70 36.70 36.70
36.65 36.65 36.65 36.65 36.65 36.65 36.65 36.65 36.65 36.65 36.65 36.65 36.65 36.65 36.65 36.65 36.65 36.65 36.65 36.65 36.65
36.60 36.60 36.60 36.60 36.60 36.60 36.60 36.60 36.60 36.60 36.60 36.60 36.60 36.60 36.60 36.60 36.60 36.60 36.60 36.60 36.60
36.55 36.55 36.55 36.55 36.55 36.55 36.55 36.55 36.55 36.55 36.55 36.55 36.55 36.55 36.55 36.55 36.55 36.55 36.55 36.55 36.55
36.50 36.50 36.50 36.50 36.50 36.50 36.50 36.50 36.50 36.50 36.50 36.50 36.50 36.50 36.50 36.50 36.50 36.50 36.50 36.50 36.50
36.45 36.45 36.45 36.45 36.45 36.45 36.45 36.45 36.45 36.45 36.45 36.45 36.45 36.45 36.45 36.45 36.45 36.45 36.45 36.45 36.45
36.40 36.40 36.40 36.40 36.40 36.40 36.40 36.40 36.40 36.40 36.40 36.40 36.40 36.40 36.40 36.40 36.40 36.40 36.40 36.40 36.40
36.35 36.35 36.35 36.35 36.35 36.35 36.35 36.35 36.35 36.35 36.35 36.35 36.35 36.35 36.35 36.35 36.35 36.35 36.35 36.35 36.35
36.30 36.30 36.30 36.30 36.30 36.30 36.30 36.30 36.30 36.30 36.30 36.30 36.30 36.30 36.30 36.30 36.30 36.30 36.30 36.30 36.30
36.25 36.25 36.25 36.25 36.25 36.25 36.25 36.25 36.25 36.25 36.25 36.25 36.25 36.25 36.25 36.25 36.25 36.25 36.25 36.25 36.25
36.20 36.20 36.20 36.20 36.20 36.20 36.20 36.20 36.20 36.20 36.20 36.20 36.20 36.20 36.20 36.20 36.20 36.20 36.20 36.20 36.20
36.15 36.15 36.15 36.15 36.15 36.15 36.15 36.15 36.15 36.15 36.15 36.15 36.15 36.15 36.15 36.15 36.15 36.15 36.15 36.15 36.15
36.10 36.10 36.10 36.10 36.10 36.10 36.10 36.10 36.10 36.10 36.10 36.10 36.10 36.10 36.10 36.10 36.10 36.10 36.10 36.10 36.10
36.05 36.05 36.05 36.05 36.05 36.05 36.05 36.05 36.05 36.05 36.05 36.05 36.05 36.05 36.05 36.05 36.05 36.05 36.05 36.05 36.05
36.00 36.00 36.00 36.00 36.00 36.00 36.00 36.00 36.00 36.00 36.00 36.00 36.00 36.00 36.00 36.00 36.00 36.00 36.00 36.00 36.00
35.95 35.95 35.95 35.95 35.95 35.95 35.95 35.95 35.95 35.95 35.95 35.95 35.95 35.95 35.95 35.95 35.95 35.95 35.95 35.95 35.95
35.90 35.90 35.90 35.90 35.90 35.90 35.90 35.90 35.90 35.90 35.90 35.90 35.90 35.90 35.90 35.90 35.90 35.90 35.90 35.90 35.90
35.85 35.85 35.85 35.85 35.85 35.85 35.85 35.85 35.85 35.85 35.85 35.85 35.85 35.85 35.85 35.85 35.85 35.85 35.85 35.85 35.85
35.80 35.80 35.80 35.80 35.80 35.80 35.80 35.80 35.80 35.80 35.80 35.80 35.80 35.80 35.80 35.80 35.80 35.80 35.80 35.80 35.80
35.75 35.75 35.75 35.75 35.75 35.75 35.75 35.75 35.75 35.75 35.75 35.75 35.75 35.75 35.75 35.75 35.75 35.75 35.75 35.75 35.75
35.70 35.70 35.70 35.70 35.70 35.70 35.70 35.70 35.70 35.70 35.70 35.70 35.70 35.70 35.70 35.70 35.70 35.70 35.70 35.70 35.70
20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40
381
Appendix | III |
Investigation reference ranges at a glance
kg 41 44 46 48 50 53 55 57 59 62 64 66 68 71 73 75 78 80 82 84 87 89 91 93 96 98 100 103 105 107 109 112 114 116 118 121 123 125 127
Weight
st 7 7 7 8 8 8 9 9 9 10 10 10 11 11 12 12 12 13 13 13 14 14 14 15 15 15 16 16 17 17 17 18 18 18 19 19 19 20 20
lb 91 96 101 106 111 116 121 126 131 136 141 146 151 156 161 166 171 176 181 186 191 196 201 206 211 216 221 226 231 236 241 246 251 256 261 266 271 276 281
Height
Table A3.1 Ovulation investigations: reference ranges for progesterone and prolactin (see Chapter 4)
384
Investigation reference ranges at a glance Appendix | III |
Table A3.2 Ovarian reserve reference ranges: FSH, LH, and E2 (see Chapter 4)
385
Acupuncture for IVF and Assisted Reproduction
386
Investigation reference ranges at a glance Appendix | III |
47 2.9 0.4
48 1.4 0.2
49 0.7 0.1
50 0 0
a
Reference values may vary between different laboratories and assays used. Therefore, laboratory reports should be checked for reference ranges
applicable to the individual patient’s results profile.
Continued
387
Acupuncture for IVF and Assisted Reproduction
Table A3.6 WHO interpretation of semen analysis (2010) (see Chapter 4)18
388
Investigation reference ranges at a glance Appendix | III |
Table A3.7 Interpretation of male factor hormone assessment (see Chapter 4)19
389
Acupuncture for IVF and Assisted Reproduction
Table A3.9 ASRM interpretation of ultrasound examination of male factor subfertility (see Chapter 4)19
390
Investigation reference ranges at a glance Appendix | III |
391
Acupuncture for IVF and Assisted Reproduction
Table A3.16 Leukocyte Antibody Detection (LAD) test reference ranges (see Chapter 12)
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1. National Collaborating Centre for 7. ASRM. Medication for inducing 14. Lee JY, Jee BC, Lee JR, et al. Age-
Women’s and Children’s Health, ovulation. A guide for patients. related distributions of anti-
Commissioned by the National Report of the ASRM, ASRM, Müllerian hormone level and anti-
Institute for Health and Clinical Birmingham, AL; 2012. müllerian hormone models. Acta
Excellence. Guideline summary. In: 8. Montoya JM, Bernal A, Borrero C. Obstet Gynecol Scand
Fertility: assessment and treatment Diagnostics in assisted human 2012;91:970–5.
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problems. NICE clinical guideline. Online 2002;5:198–210. Women’s and Children’s Health,
2nd ed. London: The Royal College 9. Practice Committee of the American Commissioned by the National
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Diagnostic evaluation of the infertile 2012;98:1407–15. and treatment for people with
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Steril 2012;98:302–7. et al. Establishment of detailed guideline. 2nd ed. London: The
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Luteal phase defect: the sensitivity hormone, follicle stimulating Gynaecologists; 2013. p. 80–132
and specificity of diagnostic methods hormone, estradiol, and progesterone [chapter 6].
in common clinical use. Fertil Steril during different phases of the 16. The Rotterdam ESHRE/
1994;62:54–62. menstrual cycle on the Abbott ASRM-sponsored PCOS consensus
4. Beltran L, Fahie-Wilson MN, ARCHITECT analyzer. Clin Chem Lab workshop group. Revised 2003
McKenna TJ, et al. Serum total Med 2006;44:883–7. consensus on diagnostic criteria and
prolactin and monomeric 11. Cahill DJ, Wardle PG. Management long-term health risks related to
prolactin reference intervals of infertility. BMJ 2002;325:28–32. polycystic ovary syndrome (PCOS).
determined by precipitation with Hum Reprod 2004;19:41–7.
12. Homburg R, Ray A, Bhide P, et al. The
polyethylene glycol: evaluation relationship of serum anti-Mullerian 17. Miyakis S, Lockshin MD, Atsumi T,
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2008;54:1673–81. ovary syndrome: a prospective classification criteria for definite
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Int Congr Ser 2004; 295–306.
13. Seifer DB, Baker VL, Leader B. Age-
1266:57–62. specific serum anti-Müllerian 18. WHO. Reference values and semen
6. Prolactin: MedlinePlus medical hormone values for 17,120 women nomenclature. In: Cooper TG, editor-
encyclopedia. Available from: http:// presenting to fertility centers within in-chief. WHO laboratory manual for
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19 April 2013].
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World Health Organization; 2010. an Endocrine Society clinical IVF cycle. Fertil Steril
p. 223–6 [Appendix 1]. practice guideline. J Clin Endocrinol 2011;95:1178–81.
19. Practice Committee of American Metab 2011;96:1911–30. 29. Revelli A, Casano S, Piane LD, et al. A
Society for Reproductive Medicine. 25. The Association for Clinical retrospective study on IVF outcome
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20. Larson-Cook KL, Brannian JD, UK guidelines for the use of thyroid and prednisolone adjuvant
Hansen KA, et al. Relationship function tests. Report of the The treatments. Reprod Biol Endocrinol
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Stalf T, et al. Influence of American Society for Reproductive TX: AJR Pub.; 2006. p. 127–40.
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23. Pearce H, Cheetham D. Diagnosis Endocrine Society clinical practice 32. Beer AE, Kantecki J, Reed J. Dr. beer’s
and management of vitamin D guideline. J Clin Endocrinol Metab treatments. In: Is your body baby-
deficiency. BMJ 2010;340:142–7. 2012;97:2543–65. friendly: “unexplained” infertility,
24. Holick MF, Binkley NC, 28. Reh A, Chaudhry S, Mendelsohn F, miscarriage and IVF failure
Bischoff-Ferrari HA, et al. et al. Effect of autoimmune thyroid explained. Houston, TX: AJR Pub.;
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prevention of vitamin D deficiency: woman during the first 35 days of an
393
Appendix | IV |
Fertility factsheets
396
Fertility factsheets Appendix | IV |
Exercise Alcohol
If you are overweight (BMI 25 kg/m2), intensive exercise The research evidence on the effects of moderate alcohol
is likely to significantly improve your fertility. If your BMI is intake and subfertility is at present mixed. There is no
normal (<25 kg/m2 but 19 kg/m2), moderate exercise is strong evidence to suggest that low to moderate alcohol
adequate. If you are underweight (BMI <19 kg/m2), ensure intake (40–80 g or 4–8 units/week) in a man harms his fer-
you do not over-exercise because this may lead to tility. Excessive alcohol intake (20 units/week) by a man
subfertility. has been shown to significantly increase how long it takes
to conceive. Therefore, limit your alcohol intake and avoid
binge drinking. Speak to your acupuncturist and/or your
Stress family doctor if you need help with reducing your alcohol
If possible, reduce your stress levels. Engage in stress- intake.
reducing activities such as hobbies, positive visualization,
meditation, and exercise. If you find it difficult to manage
your stress levels, speak to your acupuncturist, who may be Caffeine
able to help. There is no strong evidence that moderate caffeine intake
reduces fertility in men. However, you may choose to limit
your caffeine intake for general health reasons or as a way
Sexual intercourse of supporting your female partner, who may be asked to
If you and your partner have not been diagnosed with com- stop drinking all caffeinated drinks.
plete sterility (for example, absence of fallopian tubes or an
early onset menopause, very poor sperm parameters), you Recreational drugs
should carry on trying to conceive naturally.
Daily or every other day intercourse is most likely to The use of recreational drugs is strongly linked to sub-
result in conception. Timing intercourse to the fertile win- fertility. If using drugs, speak to your family doctor and/or
dow is necessary. The most reliable methods of ovulation your acupuncturist who will advise you on how to give
detection are fertile mucus days or E3G-based ovulation up. The information will be treated in a highly confidential
detection kits. Speak to your acupuncturist for more advice manner.
on this. Intercourse should be fun with emphasis on fore-
play, visual stimulation, and high and prolonged arousal.
Prescription or over-the-counter medication
Prescription or over-the-counter medication may nega-
OPTIMIZING MALE FERTILITY tively affect your sperm production and ejaculation, cause
erectile difficulties, produce changes in hormone levels,
and affect libido. Always check with your doctor or phar-
Patient’s factsheet macist if your medication is safe to take when trying to con-
ceive. Never discontinue taking your medication without
Weight first checking with the doctor who prescribed it for you.
Ideally, aim to keep your weight between a BMI of 19 and
24 kg/m2 because a BMI outside these limits has been
linked to subfertility, poor IVF outcomes, and miscarriages.
Environmental toxins
If you need to lose weight, regular exercise (minimum Exposure to environmental toxins may affect reproductive
30 min of moderately intense exercise at least three times health, although more research is needed to know exactly
a week) and a low calorie diet (1000–1200 kcal/day) is what types of chemicals should be avoided. In the mean-
recommended. However, losing weight while undergoing time, minimize your exposure to as many toxins as possi-
reproductive treatment is not recommended. ble. For example:
397
Acupuncture for IVF and Assisted Reproduction
• Delay house decoration and renovations until after marlin, Spanish mackerel). Alternatively, purified fish
reproductive treatment is finished. oil supplement with sufficiently high EPA and DHA
• Minimize the use of plastic containers, plastic food levels can be taken. If you follow a vegan diet, you can
wrapping, and canned foods. take algal oil supplements. Fish feed on algae, which is
• Ideally, organic food should be eaten and fruits and what makes fish a rich source of omega-3. Omega-3
vegetables thoroughly washed to reduce exposure to can thin your blood. If you take blood-thinning
pesticides. medication (for example, low molecular weight
• Whenever possible, use only natural cleaning products. heparin (Clexane) or aspirin), speak to your doctor
• When preparing fish, trimming the fat, removing or or nutritionist before increasing your omega-3
puncturing the skin, and not frying it may help to intake.
reduce exposure to chemicals and metals. • Zinc: is important for testosterone and sperm
• Reduce exposure to chemicals or heat when at work. production and sperm motility. In one study, taking
Consider changing your job if exposure is unavoidable. 200 mg zinc twice daily improved sperm motility and
Heat in the scrotal area may be damaging to sperm. There- reduced sperm DNA damage. Food sources of zinc are
fore, avoid situations that would cause an increase in scro- oysters (the richest source of zinc), red meat, poultry,
tal temperature (for example, sauna use, sitting down for seafood (crab, lobster).
prolonged periods of time, hot baths, use of electric blan- • Vitamin B12: dosages between 1000 and up to
kets or heated car seats, use of a laptop on your lap). 6000 mg/day taken for 2–3 months have been shown to
improve sperm count. The best sources of vitamin B12
are beef liver and clams, fish, meat, poultry, and dairy.
Nutrition • Antioxidants: help to repair sperm DNA damage. More
To improve your fertility: research needs to be done to establish exactly which
antioxidants and at what dosages are beneficial.
• Eat a diet rich in vegetables, fruits, grains, poultry, However, there is some evidence that vitamin C and E
and seafood.
are important. In one study it was found that taking 1 g
• Reduce processed meats, reduce high sugar foods, and vitamin C and 1 g vitamin E daily for 2 months
avoid a high amount of carbohydrate foods.
significantly reduced sperm DNA damage. Selenium is
• Replace full-fat dairy with low-fat dairy. another important antioxidant. Foods naturally rich in
Seek specialist nutritionist advice if you feel you need help vitamin E include nuts, seeds, and vegetable oils.
with your nutrition. Your acupuncturist may also suggest Vitamin C-rich foods are citrus fruits, red and green
other foods beneficial in your case, based on your acupunc- peppers, kiwifruit, broccoli, strawberries, cantaloupe,
ture diagnosis. baked potatoes, and tomatoes.
Supplements
Exercise
Advice in this section is provided for general information
Exercise is important for general health and fertility. In one
only. Always seek specialist advice from a nutritionist
study it was found that men who exercised for 15 h a
regarding specific micronutrients.
week had 73% higher sperm concentrations compared to
The following micronutrients are important for optimal
men who exercised <5 h a week. However, bicycling
reproductive health:
5 h/week is associated with low sperm concentrations
• Vitamin D: take a minimum of 600 IU (15 mg) vitamin and therefore must be avoided.
D per day, but you may require an even higher dose
1500–2000 IU (37.5–50 mg) per day if you are deficient
in vitamin D. Do not take more than 4000 IU (100 mg) Stress
without medical supervision. Spend as much time in
the sun as possible because sunlight helps the body to If possible, keep your stress levels down. Engage in stress-
make vitamin D. Food sources of vitamin D include reducing activities such as hobbies, positive visualization,
fish-liver oil, oily fish, egg yolks, mushrooms, and liver. meditation, and exercise. If you find it difficult to manage
your stress levels, speak to your acupuncturist, who may be
• Omega-3: DHA and EPA are two types of omega-3 that
have been shown to have beneficial effect on able to help.
reproductive health. Ensure you consume at least 200–
300 mg of DHA plus EPA per day. The best source of
omega-3 is oily fish (salmon, sardines, herring, catfish,
Sexual intercourse
halibut, canned tuna). Avoid fish high in mercury If you and your partner have not been diagnosed with com-
(tilefish, shark, swordfish, king mackerel, fresh or plete sterility (for example, absence of fallopian tubes or an
frozen tuna steaks (not canned), orange roughy, early onset menopause in your partner, or if you have very
398
Fertility factsheets Appendix | IV |
poor sperm parameters), you should carry on trying to con- to your acupuncturist for more advice on this. Intercourse
ceive naturally. should be fun with emphasis on foreplay, visual stimula-
Daily or every other day intercourse is most likely to tion, and high and prolonged arousal. Ensure that you ejac-
result in conception. Timing intercourse to the fertile win- ulate regularly (that is, have an ejaculation every 2–5 days)
dow is necessary. Your female partner may need to use ovu- outside of the fertile window because this has been shown
lation detection methods such as tracking fertile mucus to improve sperm, especially in men with suboptimal
days or using E3G-based ovulation detection kits. Speak sperm parameters.
399
Appendix |V|
Commonly used medications in ART
Ovarian Gonadorelin Buserelin Man-made gonadorelin, acts on Suprefact 200–500 mg daily injection from SC Menopausal symptoms, such
suppression; analogues LHRH receptors initially causing cycle day 21 of suppression as hot flushes, increased
Prevention (GnRH agonist) increase in FSH and LH, but after phase or cycle day 1 of sweating, vaginal dryness,
of 10 days desensitizes the pituitary stimulation phase until hCG dyspareunia, loss of libido,
premature gland and leads to reduction in administration headaches
ovulation FSH and LH production, which
Nafarelin Synarel 200 mg/spray in each nostril daily Nasal
inhibits androgen and oestrogen
from cycle day 21 of suppression spray
production
phase or cycle day 2 of
stimulation phase until hCG
administration
GnRH Cetrorelix Stops LH production by blocking Cetrotide 250 mg from cycle day 5 of SC Nausea, headaches
antagonist LHRH action stimulation phase until hCG
Ganirelix Orgalutran SC
administration
Ovulation Pulsed Gonadorelin Synthetic gonadotropin- Factrel 5 mg every 90 min. If ineffective, IV Rarely nausea, headaches,
induction; LHRH/GnRH acetate releasing hormone (GnRH), can be increased incrementally abdominal pain, increased
Lutrepulse
Ovarian which stimulates the production up to 20 mg per 90 min pulse menstrual bleeding
stimulation and release of LH and to lesser interval
degree FSH
Anti-oestrogen Clomiphene citrate Blocks oestrogen receptors in the Clomid 50–150 mg/day, days 1–5 of T Hot flushes, abdominal
hypothalamus, thus allowing for menstrual cycle discomfort
Clomifene
continued FSH/LH production
(generic)
and follicular development
Serophene
Gonadotrophin Menotrophin FSH/LH Purified extract of human post- Menopur Ovulation induction: IM/SC Gastrointestinal disturbances,
(Human menopausal urine containing 150–450 IU/day for 12 days headache, joint pain, fever
Merional IM/SC
Menopausal FSH and LH (ratio 1:1) used to ART:
Gonadotrophin stimulate follicular development Repronex 150–450 IU/day for 12 days IM/SC
hMG)
Urofollitropin FSH Purified extract of human post- Bravelle IM/SC
menopausal urine containing
Fertinorm IM/SC
FSH used to stimulate follicular
HP
development
Fostimon IM/SC
Gonadotrophin Lutropin alfa Recombinant (man-made) LH Luveris Ovulation induction: SC Nausea, vomiting, abdominal
(Recombinant used with recombinant human 75–300 IU/day for up to 30 days and pelvic pain, headaches,
LH) FSH to stimulate follicular ART: somnolence
development 150–450 IU/day for 10 days
Gonadotrophin Follitropin alfa Recombinant (man-made) FSH Gonal-F IM/SC Gastrointestinal disturbances,
(Recombinant used to stimulate follicular headache, joint pain, fever
FSH) development
Oocyte Chorionic Chorionic Urinary hCG obtained from the Pregnyl 5000–10,000 IU injection day IM/SC Oedema, headache, tiredness,
maturation gonadotrophin gonadotrophin urine of pregnant women used in after last dose of gonadotrophin mood changes, gynaecomastia
oocyte maturation
Choriogonadotrophin Recombinant (man-made) hCG Ovitrelle 250 mg injection day after last SC Nausea, vomiting, abdominal
alfa used in oocyte maturation dose of gonadotrophin pain, headache, tiredness
Luteal/ Progestogen Progesterone Used for luteal phase and early Crinone 90 mg (8% gel)/day from VG Menstrual disturbance, PMT
endometrial pregnancy support ovulation/egg retrieval for up to (bloating, fluid retention,
support 12 weeks of pregnancy or breast tenderness), weight
discontinue on negative change, nausea, headache,
pregnancy test dizziness, insomnia,
drowsiness, depression,
Cyclogest 200 mg daily to 400 mg twice PE
change in libido. Pain,
daily from ovulation/egg retrieval
diarrhoea and flatulence (with
for up to 10 weeks of pregnancy
rectal administration)
or discontinue on negative
pregnancy test
WHO grade Insulin sensitizer Metformin Used in PCO/PCOS patients to Metformin 500–2000 mg split into 2–3 T Anorexia, nausea, vomiting,
II ovulatory hydrochloride lower insulin levels, which leads (generic) doses/day diarrhoea, abdominal pain,
disorders to lower androgen levels and taste disturbance
makes ovaries more responsive
to own FSH
Ovulation Dopamine Bromocriptine Reduces the amount of prolactin Parlodel 1.25 mg/evening for min 7–14 T Nausea, constipation,
Appendix | V |
induction (in agonists released by the pituitary days. Dose can be increased by headaches, hypotension,
patients 1.25 every 2 weeks if no effect. drowsiness, dyskinesia,
with high Discontinued on positive pathological gambling,
prolactin pregnancy test increased libido,
levels) hypersexuality, leg cramps,
Cabergoline Dostinex 1–2 mg/week until pregnant
alopecia, peripheral oedema
Continued
403
404
Blood Antiplatelet Acetylsalicylic acid Decreases platelet aggregation Aspirin 75–100 mg daily starting usually T Bronchospasm,
thinners and inhibits thrombus formation on day 5 of stimulated cycle. Stop gastrointestinal irritation,
for 1–2 days at egg retrieval. haemorrhage
Continue until 12 weeks
gestation, possibly longer.
Discontinue on negative
pregnancy test
Sources: BNF.Org. Available from: http://bnf.org/bnf/index.htm [accessed 29 January 2012]. European medicines agency – find medicine. Available from: http://www.ema.europa.eu/ema/index.
jsp?curl¼/pages/medicines/landing/epar_search.jsp&mid¼WC0b01ac058001d124 [accessed 29 January 2012]. Approved drugs. Available from: http://www.fda.gov/Drugs/InformationOnDrugs/
ApprovedDrugs/default.htm [accessed 29 January 2012]. Drug, otcs & herbals | medscape reference. Available from: http://reference.medscape.com/drugs [accessed 29 January 2012].
Keys: IM, intramuscular injection; IV, intravenous injections; SC, subcutaneous injections; VG, vaginal gel; T, tablets; P, patches; PE, pessaries.
Appendix | VI |
Medications known to adversely affect fertility
Table A6.1
Reproduced with permission from Anderson K, Nisenblat V, Norman R. Lifestyle factors in people seeking infertility treatment – a review. Aust N Z J
Obstet Gynaecol 2010;50(1):8–20. doi:10.1111/j.1479-828X.2009.01119.x.
406
Glossary of Orthodox
medical terms
AH See Assisted Hatching Capacitation Changes that happen to Controlled Ovarian Stimulation
Aneuploidy The loss or gain of one or sperm inside the female (COS) for ART Pharmacological
more chromosomes reproductive tract that allow the treatment in which women are
ART See assisted reproductive sperm to become capable of stimulated to induce the
technology fertilizing the egg development of multiple ovarian
Clinical pregnancy A pregnancy follicles to obtain multiple oocytes
Assisted hatching (AH) An in vitro
diagnosed by ultrasonographic at follicular aspiration
procedure in which the zona
pellucida of an embryo is either visualization of one or more Controlled Ovarian Stimulation
thinned or perforated by chemical, gestational sacs or definitive (COS) for non-ART cycles
mechanical, or laser methods to clinical signs of pregnancy. It Pharmacological treatment for
assist separation of the blastocyst includes ectopic pregnancy. Note: women in which the ovaries are
Multiple gestational sacs are stimulated to ovulate more than
Assisted Reproductive Technology
counted as one clinical pregnancy one oocyte
(ART) All treatments or procedures
that include the in vitro handling of Clinical pregnancy rate The number COS See Controlled Ovarian
both human oocytes and sperm, or of clinical pregnancies expressed Stimulation (COS) for ART and
embryos, for the purpose of per 100 initiated cycles, aspiration Controlled Ovarian Stimulation
establishing a pregnancy. This cycles or embryo transfer cycles. (COS) for non-ART cycles
includes, but is not limited to, Note: When clinical pregnancy Cryopreservation Frozen storage of
in vitro fertilization and embryo rates are given, the denominator sperm, eggs, embryos, or ovarian
transfer, gamete intra-fallopian (initiated, aspirated, or embryo and testicular tissues
transfer, zygote intra-fallopian transfer cycles) must be specified Cumulative delivery rate with at
transfer, tubal embryo transfer, Clinical pregnancy with foetal least one live born baby The
gamete and embryo heart beat Pregnancy diagnosed estimated number of deliveries with
cryopreservation, oocyte and by ultrasonographic or clinical at least one live born baby resulting
embryo donation, and gestational documentation of at least one from one initiated or aspirated
surrogacy foetus with a heart beat. It includes ART cycle including the cycle when
Biochemical pregnancy (preclinical ectopic pregnancy fresh embryos are transferred and
spontaneous abortion/ Clone A copy of a (DNA) molecule, a subsequent frozen/thawed ART
miscarriage) A pregnancy (stem) cell or an individual. cycles. This rate is used when less
diagnosed only by the detection of Cloning of an individual is done than the total number of embryos
hCG in serum or urine and that by replacing the nucleus of an egg fresh and/or frozen/thawed have
does not develop into a clinical cell with the genetic material from been utilized from one ART cycle.
pregnancy a somatic (non-germ) cell. Note: The delivery of a singleton,
Blastocyst An embryo, 5 or 6 days Cloning can also be done to twin, or other multiple pregnancy is
after fertilization, with an inner produce stem cells, the registered as one delivery
cell mass, outer layer of undifferentiated early cells from Delivery The expulsion or extraction
trophectoderm, and a fluid-filled which all types of cells develop. of one or more foetuses from the
blastocoele cavity This technique may in future mother after 20 completed weeks
enable people to access life-saving of gestational age
Cancelled cycle An ART cycle in
treatments tailor made from their Delivery rate The number of
which ovarian stimulation or
own DNA deliveries expressed per 100
monitoring has been carried out
with the intention to treat, but did Congenital anomalies All structural, initiated cycles, aspiration cycles,
not proceed to follicular aspiration functional and genetic anomalies or embryo transfer cycles. When
or, in the case of a thawed embryo, diagnosed in aborted foetuses, at delivery rates are given, the
to embryo transfer birth or in the neonatal period denominator (initiated, aspirated,
or embryo transfer cycles) must be which cycle monitoring is carried embryo age at freezing from the
specified. It includes deliveries that out with the intention of transfer date of the FET cycle
resulted in the birth of one or more transferring a frozen/thawed Gestational carrier (surrogate) A
live babies and/or stillborn babies. embryo or frozen/thawed woman who carries a pregnancy
Note: The delivery of a singleton, embryos. Note: An FET cycle is with an agreement that she will
twin, or other multiple pregnancy initiated when specific medication give the offspring to the intended
is registered as one delivery is provided or cycle monitoring is parent(s). Gametes can originate
Early neonatal death Death of a started with the intention to treat from the intended parent(s) and/
live born baby within 7 days of Frozen/thawed oocyte cycle An or a third party (or parties)
birth ART procedure in which cycle Gestational sac A fluid-filled
Ectopic pregnancy Implantation of monitoring is carried out with the structure associated with early
the embryo outside the uterus intention of fertilizing thawed pregnancy, which may be located
Elective embryo transfer The oocytes and performing embryo inside or outside the uterus (in case
transfer of one or more embryos, transfer of an ectopic pregnancy)
selected from a larger cohort of Fertilization A sperm penetrates the GIFT See Gamete Intra-Fallopian
available embryos egg leading to a combination of Transfer
Embryo The product up to 8 weeks genetic material resulting in a Hatching The process by which an
after fertilization, later it is called a fertilized egg embryo at the blastocyst stage
foetus Foetal death (stillbirth) Death separates from the zona pellucida
Embryo donation cycle Transfer of prior to the complete expulsion or High-order multiple A pregnancy or
an embryo that did not originate extraction from its mother of a delivery with three or more
from the recipient and her partner product of fertilization, at or foetuses or neonates
Embryo/foetus reduction A after 20 completed weeks of ICSI See Intra-Cytoplasmic Sperm
procedure to reduce the number of gestational age. The death is Injection
viable embryos or foetuses in a indicated by the fact that, after such Implantation The attachment and
multiple pregnancy separation, the foetus does not subsequent penetration by the
Embryo recipient cycle (See embryo breathe or show any other evidence zona-free blastocyst (usually in the
donation cycle) of life such as heart beat, umbilical endometrium) that starts 5–7 days
cord pulsation, or definite after fertilization
Embryo Transfer (ET) The procedure
movement of voluntary muscles
in which one or more embryos are Implantation rate The number of
placed in the uterus or fallopian Foetus The product of fertilization gestational sacs observed, divided
tube from completion of embryonic by the number of embryos
Embryo transfer cycle An ART cycle development, at 8 completed transferred
in which one or more embryos are weeks after fertilization, until IMSI See Intra-Cytoplasmic
transferred into the uterus or abortion or birth Morphologically selected Sperm
fallopian tube Follicle A fluid filled sac that contains Injection
Endometriosis Condition where an immature egg. Located in the In Vitro Fertilization (IVF)
endometrial tissue grows in areas ovaries, follicles develop each Fertilization of an egg by sperm in
other than the uterine cavity cycle, one ovulates into an egg a laboratory dish
ET See Embryo Transfer Full-term birth A live birth or Induced abortion The termination
ESHRE European Society of Human stillbirth that takes place between of a clinical pregnancy, by
Reproduction and Embryology 37 completed and 42 completed deliberate interference that takes
weeks of gestational age place before 20 completed weeks
Extremely low birth weight Birth
weight less than 1000 g Gamete A reproductive cell, egg in of gestational age (18 weeks’ post
females and sperm in males fertilization) or, if gestational age
Extremely preterm birth A live birth
Gamete Intra-Fallopian Transfer is unknown, of an embryo/foetus
or stillbirth that takes place after at
(GIFT) An ART procedure in which of less than 400 g
least 20 but less than 28 completed
weeks of gestational age both gametes (oocytes and Infertility A disease of the
spermatozoa) are transferred to the reproductive system defined by the
FER See Frozen/thawed Embryo
fallopian tubes failure to conceive after 12 months
Transfer cycle
Gestational age Age of an embryo or of regular unprotected sexual
FET See Frozen/thawed Embryo intercourse. Different reproductive
foetus calculated by adding
Transfer cycle
2 weeks (14 days) to the number of health bodies may use a different
Frozen Embryo Replacement (FER) definitions(s) for infertility
completed weeks since
See Frozen/thawed Embryo
fertilization. Note: For frozen/ Initiated cycle An ART cycle in which
Transfer
thawed embryo transfers, an the woman receives specific
Frozen/thawed Embryo Transfer estimated date of fertilization is medication for ovarian stimulation,
(FET) cycle An ART procedure in computed by subtracting the or monitoring in the case of natural
408
Glossary of Orthodox medical terms
cycles, with the intention to treat, compounds, with the intent to limit systemic response to ovarian
irrespective of whether follicular the number of oocytes obtained for stimulation characterized by a
aspiration is attempted IVF to fewer than seven wide spectrum of clinical and
Intra-Cytoplasmic Morphologically Miscarriage/preclinical laboratory manifestations. It is
Selected Sperm Injection (IMSI) spontaneous abortion classified as mild, moderate, or
Fertilization method in which Pregnancy diagnosed by the severe according to the degree of
spermatozoa are inspected and detection of hCG in serum or urine abdominal distention, ovarian
selected under ultra-magnification that does not develop into a enlargement, and respiratory,
(6300 ) and then injected into clinical pregnancy haemodynamic, and metabolic
the egg Missed abortion/miscarriage A complications
Intra-Cytoplasmic Sperm Injection clinical abortion where the Ovarian torsion The partial or
(ICSI) Procedure in which an egg is embryo(s) or foetus(es) is/are complete rotation of the ovarian
fertilized by injecting a single nonviable and is/are not expelled vascular pedicle that causes
sperm into the egg spontaneously from the uterus obstruction to ovarian blood flow,
Intra-Uterine Insemination (IUI) Modified natural cycle An IVF potentially leading to necrosis of
The insemination of washed procedure in which one or more ovarian tissue
semen directly into the uterus oocytes are collected from the Ovulation Induction (OI)
IUI See Intra-Uterine Insemination ovaries during a spontaneous Pharmacological treatment of
IVF See In Vitro Fertilization menstrual cycle. Drugs are women with anovulation or
administered with the sole oligo-ovulation with the
Live birth The complete expulsion or
purpose of blocking the intention of inducing normal
extraction from its mother of a
spontaneous LH surge and/or ovulatory cycle
product of fertilization,
irrespective of the duration of the
inducing final oocyte maturation Percutaneous Epididymal Sperm
pregnancy, which, after such Motile Sperm Organelles Aspiration (PESA) Collection of
separation, breathes or shows Morphology Examination sperm under local anaesthesia by
any other evidence of life such as (MSOME) Is a method of sperm needle aspiration of the
heart beat, umbilical cord examination under high epididymis
pulsation, or definite movement magnification (6000–8000 ), Perinatal mortality Foetal or
of voluntary muscles, irrespective which can detect morphological neonatal death occurring during
of whether the umbilical cord has sperm abnormalities, which late pregnancy (at 20 completed
been cut or the placenta is standard semen analysis could weeks of gestational age and later),
attached miss during childbirth and up to 7
Live birth delivery rate The number MSOME See Motile Sperm Organelles completed days after birth
of deliveries that resulted in at least Morphology Examination PESA See Percutaneous Epididymal
one live born baby expressed per Multiple gestation/birth A Sperm Aspiration
100 initiated cycles, aspiration pregnancy/delivery with more PGD See Pre-implantation Genetic
cycles or embryo transfer cycles. than one foetus/neonate Diagnosis
When delivery rates are given, the Natural cycle IVF An IVF procedure PGS See Pre-implantation Genetic
denominator (initiated, aspirated, in which one or more oocytes are Screening
or embryo transfer cycles) must be collected from the ovaries during a Polycystic Ovarian Syndrome
specified spontaneous menstrual cycle (PCOS) A condition characterized
Low birth weight Birth weight less without any drug use by irregular or absent
than 2500 g Neonatal death Death of a live born menstruation, acne, obesity, and
MESA See Micro-Epididymal Sperm baby within 28 days of birth excess hair growth
Aspiration Neonatal period The time interval Post-term birth A live birth or
MESE See Micro-Epididymal Sperm that commences at birth and ends stillbirth that takes place after 42
Extraction 28 completed days after birth completed weeks of gestational age
Micro-Epididymal Sperm OHSS See Ovarian Hyper Stimulation Pre-implantation Genetic
Aspiration (MESA) Surgical Syndrome Diagnosis (PGD) Diagnostic
collection of sperm direct from the Oocyte donation cycle A cycle in technique involving genetic tests
epididymis (tube that carries which oocytes are collected from a on an embryo or a polar body (a
sperm out of the testis). Used when donor for clinical application or cell structure inside the egg).
a blockage in the epididymis leads research Usually done when the embryo is
to absence of sperm in the semen Oocyte recipient cycle An ART cycle at the 6–8 cell stage. One cell is
Mild ovarian stimulation for IVF A in which a woman receives oocytes removed for analysis of its DNA or
procedure in which the ovaries are from a donor chromosomes to determine if the
stimulated with either embryo is likely to develop a
Ovarian Hyper Stimulation
gonadotropins and/or other genetic disease
Syndrome (OHSS) An exaggerated
409
Acupuncture for IVF and Assisted Reproduction
Pre-implantation Genetic according to local intra-uterine including all fresh cycles and all
Screening (PGS) Technique to growth charts frozen/thawed ART cycles. This
check if an embryo has the correct Sperm donation cycle See sperm rate is used when all of the
number of chromosomes. Used recipient cycle embryos fresh and/or frozen/
particularly for older women Sperm recipient cycle An ART cycle thawed have been utilized from
(at increased risk of chromosomal in which a woman receives one ART cycles. Note: The delivery
abnormalities) and for women spermatozoa from a donor who is of a singleton, twin or other
who have had recurrent someone other than her partner multiple pregnancy is registered as
miscarriages (often due to one delivery
SPOM See Simulated Physiological
chromosomal abnormalities). It is TTC Time To Conception
Oocyte Maturation
still in the experimental phase, Vanishing sac(s) or embryo(s)
Spontaneous abortion/
since it is not yet evidence based Spontaneous disappearance of
miscarriage The spontaneous loss
Preterm birth A live birth or stillbirth one or more gestational sacs or
of a clinical pregnancy that occurs
that takes place after at least 20 but embryos in an ongoing
before 20 completed weeks of
before 37 completed weeks of pregnancy, documented by
gestational age (18 weeks post
gestational age ultrasound
fertilization) or, if gestational age
Recurrent spontaneous abortion/ is unknown, the loss of an Very low birth weight Birth weight
miscarriage The spontaneous loss embryo/foetus of less than 400 g less than 1500 g
of two or more clinical Very preterm birth A live birth
STDs Sexually Transmitted Diseases
pregnancies or stillbirth that takes place
STIs Sexually Transmitted Infections
Reproductive surgery Surgical after at least 20 but less than
Stillbirth See Foetal death
procedures performed to diagnose, 32 completed weeks of
conserve, correct, and/or improve TCM Traditional Chinese Medicine
gestational age
reproductive function TESA See Testicular Sperm Aspiration
Vitrification An ultra-rapid freezing
SET See Single Embryo Transfer TESE See Testicular Sperm Extraction method for eggs and embryos. It
Severe Ovarian Hyper Stimulation Testicular Sperm Aspiration (TESA) avoids the damage usually caused
Syndrome (severe OHSS) Severe Needle aspiration of the testis to in freezing from ice crystals
OHSS is defined to occur when collect sperm, usually carried out ZIFT See Zygote Intra-Fallopian
hospitalization is indicated. (See in cases where PESA has been Transfer
definition of Ovarian Hyper unsuccessful
Zygote A diploid cell resulting from
Stimulation Syndrome) Testicular Sperm Extraction (TESE) the fertilization of an oocyte by a
Single Embryo Transfer (SET) Done when other [sperm] spermatozoon, which subsequently
Method of selecting one embryo extraction methods were divides to form an embryo
for transfer to lower the risk of unsuccessful
Zygote Intra-Fallopian Transfer
multiple pregnancies Total delivery rate with at least (ZIFT) A procedure in which
Small for gestational age Birth one live birth The estimated total zygote(s) is/are transferred into
weight less than 2 standard number of deliveries with at least the fallopian tube
deviations below the mean or one live born baby resulting from
less than the 10th centile one initiated or aspirated ART cycle
REFERENCES
1. Assisted Reproductive Technology Committee for Monitoring Assisted morphologically selected sperm
(ART) – glossary. Available from: Reproductive Technology (ICMART) injection versus intracytoplasmic
http://www.eshre.eu/ESHRE/ and the World Health Organization sperm injection: a step toward a
English/Guidelines-Legal/ (WHO) revised glossary on ART clinical algorithm. Fertil Steril
ART-glossary/page.aspx/1062 terminology, 2009. Hum Reprod 2013;99:1290–3.
[accessed 26 January 2013]. 2009;24:2683–87.
2. Zegers-Hochschild F, Adamson GD, 3. Klement AH, Koren-Morag N,
de Mouzon J, et al. The International Itsykson P, et al. Intracytoplasmic
410
Glossary of Traditional
Chinese Medicine
(TCM) terms
Acupuncture (Zhen Jiu) TCM Brain (Nao) An Extraordinary Fu. Its development and reproduction. It
treatment modality characterized growth and function is associated is a combination of Pre-Natal
by the insertion of solid with Kidney Jing (Essence) (congenital) and Post-Natal
acupuncture needles into specific Cold (Han) One of the Six Evils or (acquired) Jing (Essences)
locations (acupuncture points) on disease causing Qi. Cold can be Extraordinary Organ (Qi Heng Zhi
the surface of the body for either due to external Fu) Organs, which store Yin
therapeutic purposes environmental Cold or internally Essence (in the same way as Zang
Acupuncture point (Xue Wei) generated, for example from Yang organs) and they also resemble the
Specific locations on the surface of deficiency structure of the Fu organs. The
the body that are linked to Conception Vessel (Ren Mai) One Extraordinary Organs are the
meridians and network vessels. An of the eight Extraordinary Vessels Brain, Uterus, Marrow, Bones,
acupuncture point has an Dampness (Shi) One of the Six Evils Vessels and the Gall Bladder
anatomical location, needling or disease causing Qi. Dampness Fire (Huo) (1) A term that represents
specification, action and can be either due to external the motive force of life, a type of
indication. A therapeutic change environmental Dampness or physiological fire which is
can be induced through Internal Dampness resulting from, transformed through Yang Qi. For
stimulating these points by, for for example, Spleen failing to example, the Ming Men (Fire of Life).
example, inserting into them fine transform and transport fluids (2) One of the Six Evils, disease
needles (acupuncture), heating Damp-Heat (Shi Re) A combination causing Qi. Pathological Fire can also
them (moxibustion) or by of Dampness and Heat be caused by internal disharmony,
applying pressure to them for example Liver pathology
Dietary irregularities (Yin Shi Shi
Blood (Xue) A TCM concept, which is Five Phases (Wu Xing) A TCM
Tiao) A miscellaneous cause of
different to the Orthodox medical diagnostic system of associated
disease due to irregularities in a
understanding of blood. It is a vital correspondences. The Five Phases are
person’s diet. For example, eating
substance derived from Gu Qi (food Wood, Fire, Earth, Metal, and Water
excessively or irregularly, eating an
Qi) by the Stomach and Spleen. The Food Qi (Gu Qi) Qi derived from
excessive quantity of raw, cold,
Heart governs Blood, Blood food and water
hot, sweet or fatty foods,
circulates through the Vessels (Mai) Fu Yang organs. The Fu organs include
consuming too much alcohol
and nourishes all of the body. Blood the Stomach, Small Intestine, Large
Eight Principles (Ba Gang) A TCM
brings and offers life to the Body, Intestine, Gall Bladder, Bladder,
diagnostic system of the
Mind and Spirit. For example, it is Triple Burner. They are paired with
classification of disease, which
responsible for sensation and their Zang organs. Fu organs
helps to identify syndromes and
perception. Blood is interrelated ‘decompose’ food and process
formulate a treatment plan. The
with Qi. It has a close relationship ‘matter’, and eliminate waste
Eight Principles are Interior/
with the Liver, Spleen and Kidney products from the body
Exterior, Hot/Cold, Full/Empty,
Blood Deficiency/Vacuity (Xue Xu) Girdle Vessel (Dai Mai) One of the
Yin/Yang
Pathology determined by signs of eight Extraordinary Vessels
Essence (Jing) The essential
insufficient Blood
substance of the body. It Governing Vessel (Du Mai) One of
Blood-Heat (Xue Re) A pathological determines and maintains life the eight Extraordinary Vessels
condition characterized by signs of processes, including the
Heat in the Blood Gu Qi See Food Qi
constitution of a person. It is Heart (Xin) One of the five Zang
Blood Stasis (Xue Yu) Impaired flow responsible for growth, organs. The Heart governs Blood,
of Blood
controls Blood vessels, stores the Summer Heat, Dampness, Dryness and then sends this to the Heart
Mind and Spirit (also known as the Six Excesses or and Spleen
Heat (Re) One of the Six Evils or Six Evil Qi). Internal Pathogenic Syndrome or Pattern Identification
disease causing Qi. Heat is a Factors include: Dryness, Wind, (Bian Zheng) A TCM classification
manifestation of Fire, a Cold, Dampness, Fire. Pathogenic and staging of a disease, derived
pathological and lesser form. Heat Factors can also be disease causing through careful examination of
can be either due to external agents such as Phlegm or Blood clinical signs and symptoms
environmental Heat or Internal Stasis Tian Gui See Heavenly Gui
Heat resulting from, for example, Penetrating Vessel (Chong Mai) Uterus (Zi Gong) An Extraordinary
Yin Deficiency One of the Eight Extraordinary Organ. It is interrelated with
Heavenly Gui/Heavenly Water/ Vessels the Extraordinary Vessels and
Heavenly Tenth (Tian Gui) A Phlegm (Tan) A thick and sticky has a close association with the
TCM concept, which represents a substance which can be either a Kidney, Liver, Heart and
person’s reproductive potential. It cause of a disease or a product of a Spleen. The Uterus controls
is said to ‘arrive’ in girls at the age disease. Phlegm may originate menstruation, conception and
of 14 and in boys at the age of 16, from internal disharmony of the pregnancy
peaks in the early /20s and declines Lung, Spleen and Kidney or Uterus Channel (Bao Luo) A
as women and men age. Tian Gui through Fire condensing fluids. Channel that joins the Kidney and
also refers to ‘original Yin’ and Dietary irregularities may also Uterus together
‘menstruation’ cause Phlegm. Dampness over
Uterus Vessel (Bao Mai) A Vessel
Jing See Essence time may lead to Phlegm
that joins the Heart and Uterus
Kidney (Shen) One of the five Zang Post-Natal Jing (Essence), Post- together
organs. The Kidney is the basis for Heaven Qi or later Heaven (Hou
Wind (Feng) One of the Six Evils or
Pre-Natal Jing (Essence), it stores Tian) The constitution of a person,
disease causing Qi. Wind can be
Jing (Essence) and governs which is acquired after their birth
either due to external
reproduction under the influence of the Stomach
environmental Wind or internally
Liver (Gan) One of the five Zang and Spleen
generated, for example from Liver
organs. The Liver stores and Pre-Natal Jing (Essence)/Pre- pathology. Wind easily combines
regulates Blood and governs the Heaven Qi or Earlier Heaven with other Pathogenic Factors
flow of Qi (Xian Tian) The constitution of the
Yang A concept opposite to Yin. Yang
Lung (Fei) One of the five Zang person (or embryo) passed to
represents for example day,
organs. The Lungs govern Qi and them by their parents at the time of
brightness, activity; whereas Yin
respiration and significantly conception. Pre-Natal Jing
represents night, darkness and rest
influence other Zang organs (Essence) is under the influence of
Yin A concept opposite to Yang. Yin
the Kidney
Menstrual irregularities (Yue Jing represents for example night,
Bu Tiao) Irregular menstrual cycles Qi The life force present in all living
darkness, and rest; whereas Yang
and abnormalities of the flow of things. It is formed by the
represents day, brightness and
menstruation such as the colour, interaction between Yin and Yang.
activity
amount and consistency of Qi flows in the body and provides
Yin Yang An ancient TCM concept
menstruation vital energy to the organs and
tissues that represents two opposing, yet
Moxibustion (Jiu Fa) A TCM mutually dependent forces. Yin
treatment technique involving Source Qi See Original Qi
Yang is a fundamental concept
heating acupuncture points and/or Spleen (Pi) The Spleen is one of the associated with TCM theoretical
individual areas of the body by five Zang organs and is connected constructs, anatomy, physiology,
burning a herb called mugwort with the functions of the Stomach. diagnosis and clinical practice
close to these areas The Spleen has an important
Zang A Yin organ. The Zang organs
Original Qi or Source Qi (Yuan Qi) role in the formation of Qi and
include the Heart, Liver, Lung,
The original supply of Yin and Blood
Spleen, Kidney. Zang organs
Yang Stagnation (Zhi) Slow or static produce and store Jing (Essence)
Pathogenic Factor or Evil Qi (Xie Qi) movement of Qi and/or Blood
Zangfu Zang and Fu internal organs.
Disease causing Qi, which affects Stomach (Wei) A Fu organ The Zangfu is an organ system that
the health of a person. Pathogenic connected with the functions of consists of functional
Factors can be either external or Spleen. It is involved in the interrelationships between the
internal. External Pathogenic formation of Blood by receiving Zang and Fu
Factors include: Wind, Cold, Fire, and digesting Gu Qi (Food Qi)
412
Glossary of Traditional Chinese Medicine (TCM) terms
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413
Index
Note: Page numbers followed by b effectiveness in tubal infertility, 188b poor follicular development
indicate boxes, f indicate figures and t for Empty Heat/Fire, 125, 126t preventative treatment, 277
indicate tables. for endometriosis, 206–207, 208f rescue treatment, 277
ethical fertility, 343–345, 344b for prevention of poor sperm
for failed treatment cycle, 348t production, 281
frequency and discharge, 351t refusing to treat patient, 345
A for Heart Blood Deficiency, role of, at key stages of ART, 155
117, 118t for secondary infertility, 213
Abdominal diagnosis, in subfertility,
for Heart Qi Stagnation, for Spleen and Stomach Qi Deficiency,
from TCM perspective, 106–107,
119, 119t 121, 121t
107f
for Heart Yin Deficiency, for Spleen Qi Deficiency, 120, 120t
Abdominal palpation, as therapeutic
119, 119t and stress/anxiety in fertility patients,
tool, 107b
for Heat/Fire, 124–125, 125t 173
Absent vas deferens, 214
influence on late secondary to for suboptimal endometrial lining,
Acquired uterine conditions, 313
preovulatory follicles (190-0 days 280
Acrosome reaction, 61
before ovulation), 33 therapeutic relationship in, 339–346
assay, 92
influence on primordial, primary, and care, 340–341
Acupuncture
early secondary follicles (360 and challenge and performance, 341
algorithm of, for Ovarian Hyper-
190 days before ovulation), 33 effect of subfertility on patients, 342
Stimulation Syndrome (OHSS),
for irregular cycle syndromes, 220f mutuality, 339–340
293f, 294–295
for Kidney Jing (essence) Deficiency, return to mutuality, 341–342
ART, BBT charting in, 127f, 127t
109, 110t trust, 340
during Assisted Reproductive
for Kidney Yang Deficiency, 112–113, for thyroid disease, 200–202, 203f
Technology, 237–274
112t treatment for tubal blockage, 186
confounding factors, 252
for Kidney Yin Deficiency, 111, 111t for tubal factor infertility, 186t
control intervention, 249
legal and ethical considerations for, Acupuncturists
critique of, 247–253
342–345 fertility
dose of acupuncture, 249–250
for Liver Blood Deficiency, 114–115, implications for, 297–299
individualization of treatment, 249
114t role of, 155–156
male factor, 252–253
for Liver Blood Stasis, 116, 117t implications for, 151
outcome measures, 249
for Liver Qi Stagnation, 115–116, 115t role of
protocol, 238–239, 239b, 240t,
for male factor subfertility, 215, 216t, in difficult embryo transfer, 285
242–244
218f in fertilization failure, 282–283
sample size, 249
measuring the success of, 342 in follicular development, 279
stress of acupuncture treatment, 252
for menstrual cycle in poor embryo growth/growth
timing of acupuncture treatment,
irregularities, 221f, 222f, 224f arrest, 284
250–252
regulation, 218–223, 223f in poor sperm production, 281
for cold/coolness, 123–124, 123t
and NK cells, 328 in Repeated Implantation Failure
common medical causes of subfertility
for patient with poor/futile prognosis, (RIF), 310
in, 4
344 in suboptimal endometrial lining,
during early pregnancy, 349–351, 350t
for Phlegm-Damp, 122, 122t 280–281
effect on reproductive medicine and
for polycystic ovary syndrome, in tubal blockage, 186–188
fertility, 154–155
193–196, 195f self-care of, 351–352
415
Index
Acute pelvic pain, and endometriosis, Antimetabolites, adverse effect on effect of male factor subfertility on,
206b fertility, 405t 214
AFC. see Antral Follicle Count (AFC) Antimitotic drugs, adverse effect on effect of thyroid disease on, 199
Aftercare, 347–354 fertility, 405t for endometriosis, 206
Age Antioxidants, 398 fundamentals of, 143–160
effect on fertility, 16–17 and male fertility, 168 future steps, 347
maternal, Repeated Implantation Antiphospholipid syndrome (APS), 83 health of babies born as a result of,
Failure and, 304–305 criteria for diagnosing, 84t, 387t 342–343
Alcohol consumption, 163–164 Antipsychotic drugs, adverse effect on history, 100–102
effects of fertility, 405t egg retrieval, 101
on IVF outcome, 163 Antischistosomal drugs, adverse effect on embryo development, 102
on reproductive health, 163 fertility, 405t embryo transfer, 102
on the risk of miscarriages, 163 Antisperm antibodies (ASA), 89 fertilization, 102
in optimizing female fertility, 395 case study, 89b luteal phase, 102
in optimizing male fertility, 397 tests, 89 outcome(s), 102
recommendations for management of, Antral follicles, cyclical recruitment ovarian stimulation phase in, 101
164 (selection) and development of, ovulation induction in, 101
Traditional Chinese Medicine view of, 32–33 preparation phase, 100–101
163–164 Antral Follicle Count (AFC), 80 pretreatment stage (downregulation
Amenorrhoea, 188 ovarian reserve reference ranges, 80t stage), 101
as predictors of polycystic ovary Anxiety previous treatment cycles, 100
syndrome, 191 management of patients experiencing, minimising the risk of, while
American Fertility Society classification, about miscarrying, 322 maximising chances of
of congenital uterine anomalies, and subfertility, 8 pregnancy, 296–297
26, 26f APS. see Antiphospholipid syndrome pharmacological drugs used in,
American Society for Reproductive (APS) 149–150
Medicine (ASRM), 344 Arcuate uterus, 26, 313 preconception care in preparation for,
infertility definition, 2t Aromatase inhibitors, 149 161–184
pregnancy definition, 2 ART. see Assisted Reproductive in pregnancy, 348–349
AMH. see Anti-Müllerian hormone Technology (ART) regulation of, 343
(AMH) ART fertilization (in vitro), vs. natural risk of complications of, 348–349
Ampulla, 23–25 fertilization (in vivo), 62, 63t role of acupuncture in, 154–156
Anabolic steroids, adverse effect on Artificial insemination. see Intrauterine third-party, 148–149
fertility, 405t Insemination (IUI) timeline of major developments in,
Anaesthetics, local, adverse effect on ASA. see Antisperm antibodies (ASA) 13f
fertility, 405t Asherman’s syndrome, 313 treatment for older patient, 343
Androgen, for poor follicular Aspermia, 87t treatment planning in, 223–227
development, 276 Aspirin, in ART, 402t case intake stage, 224–226
Anger, and subfertility, 8 ASRM. see American Society for Orthodox and TCM integrated, 225f
Anovulation, 188 Reproductive Medicine (ASRM) pregnancy support, 227
Anti-inflammatory 5-ASA, adverse effect Assisted hatching, 153 preparation stage, 226
on fertility, 405t Repeated Implantation Failure and, treatment stage, 226–227
Anti-Müllerian hormone (AMH), 78–80 305 tubal pathology impact on, 186
ovarian reserve reference ranges, 79t Assisted reproduction ethics, types of treatment, 143–149, 144f
Anti-oestrogens, adverse effect on 342–343 In Vitro Fertilization as, 237
fertility, 405t Assisted Reproductive Technology Asthenoteratozoospermia, 87t
Anti-progestins, adverse effect on (ART), 347 Asthenozoospermia, 87t
fertility, 405t in acupuncture management Autoimmunity, thyroid, 314
Antiandrogens, adverse effect on fertility, with endometriosis, 208f Azoospermia, 87t
405t with PCOS, 195f
Antibiotics, adverse effect on fertility, with thyroid disease, 203f
405t advanced techniques in, 151–154 B
Antiepileptic drugs, adverse effect on BBT charting in, 127f, 127t BAcC. see British Acupuncture Council
fertility, 405t clinical issues during, 275–290 (BAcC)
Antihypertensive drugs, adverse effect on commonly used medications in, Bacterial vaginosis (BV), 85, 314
fertility, 405t 401–404, 402t Basal body temperature (BBT)
Antimalarial drugs, adverse effect on complications of, 291–300 chart template and instructions,
fertility, 405t donor, 148 379–382
416
Index
charting, 126 British Acupuncture Council (BAcC), in Classical Chinese literature, conception
advantages and disadvantages of, medical causes of subfertility, 4 and, 67–68
®
126, 127t Buserelin (Suprefact ), 237 Cleavage, 62
analysing, 126–134 BV. see Bacterial vaginosis (BV) Cleavage-stage embryo scoring systems,
in ART acupuncture practice, 127f 150–151, 151f, 151t, 152f
as diagnostic aid, 126–134 Clexane, in ART, 402t
ovulation detection method, C Clomid. see Clomiphene citrate (CC)
176–177 Caffeine, 164 Clomifene, in ART, 402t
working with, 126 effect on female fertility, 164 Clomiphene citrate (CC), 12, 149, 149b
BBT. see Basal body temperature (BBT) effect on male fertility, 164 in ART, 402t
Bicornuate uterus, 26, 313 in optimizing female fertility, 395 for ovulation disorders, 188–189
Biochemical tests, for thyroid disease, in optimizing male fertility, 397 ovulation induction with, 262
197 CAM. see Complementary and for PCOS, 192
Biopsy, endometrial, 82 Alternative Medicine (CAM) Clomiphene Citrate Challenge Test
Biphasic pattern, BBT chart, 128 Canalization defect, in congenital (CCCT), 80
Blastocysts uterine anomalies, 26 Coital practices, 174–175
versus day 2 versus day 3 transfer, Capacitation, 12, 60 Coitus. see Sexual intercourse
Repeated Implantation Failure Care Cold/coolness, 123–124, 124b
and, 305 continuity of, 344 acupuncture treatment of, 123–124,
stage in embryogenesis, 62 for patients, 340–341 123t
Blastocyst scoring systems, 151, 152t Case intake stage (review stage), in aetiology of, 123
Blastomeres, 62 Assisted Reproductive foods beneficial in, 170
Blocked fallopian tubes, 186 Technology (ART) treatment, pathology of, 123
Blood 224–226 possible consequences for
conjectural overview of production of, lifestyle factors of, 224 reproduction and ART, 123
40f medical history and diagnosis of, 224 Repeated Implantation Failure and,
menstrual, conjectural composition previous ART treatment history of, 308
from TCM point of view, 43f 224–225 signs and symptoms of, 123
relationships between Qi, Jing TCM history of, 226 Cold-Uterus, 309t
(Essence), Body Fluids, and, 40f CAT. see Chlamydia Antibody Test (CAT) Compaction, 62
in reproductive physiology from TCM Cavitation, 62 Competence, limit of, for acupuncture
perspective, 39 CCCT. see Clomiphene Citrate Challenge practice, 344
Blood Deficiency syndromes Test (CCCT) Complaint, presenting, for medical and
foods beneficial in, 169 CD56+ natural killer cells, 325, 325t fertility history taking, 97–98
in miscarriages, 318t Cervical assessment, in ovarian reserve Complementary and Alternative
Blood-Heat screening, 80 Medicine (CAM), 3
in miscarriages, 318t Cervical funnelling, 324 Conception, 59–72
Repeated Implantation Failure and, Cervical insufficiency, 313, 323–325 effect of male factor subfertility on,
310 Cervical length measurements, 214
Blood Stasis syndromes, 309t 323–324 female reproductive tract
foods beneficial in, 170 Cervical mucus, 60 sperm transportation in, 60, 61b
and infertility, 308b in ovulation detection methods, 176, transportation of embryo down,
in miscarriages, 318t 176f 62, 65f
Phlegm-Damp-Cold and, 122b Cervical shortening, 325b natural
and polycystic ovary syndrome, 194t Cervical weakness, 313 before IVF, 175b
Repeated Implantation Failure and, Cervix, 25 from TCM point of view, 67–68
308 ®
Cetrorelix (Cetrotide ), 238 prerequirements for, 23–58
in reproductive immunology, 328 Cetrotide, in ART, 402t from TCM point of view, 67–69
pathogenesis of, 329f Chinese medicine physicians, works of, in In Vitro Fertilization (IVF), 68, 68f
Blood-thinning medication reproductive history, 13–16 Conceptus stage, 63–66
in ART, 150 Chlamydia Antibody Test (CAT), 82 Confidentiality, in acupuncture practice,
and female fertility, 167b in tubal pathology, 185 344
BMI. see Body mass index (BMI) ’Chocolate cysts.’. see Endometriomas Congenital uterine anomalies/
Body Fluids, relationships between Chong Mai (Penetrating Vessel), 51 abnormalities, 312
Blood, Qi, Jing (Essence), functions of, 51 American Fertility Society
and, 40f vs. Ren Mai and Du Mai, 52t classification of, 26, 26f
Body mass index (BMI), 161 Choragon, in ART, 402t Repeated Implantation Failure and,
Bravelle, in ART, 402t Circumcision, female, and subfertility, 6 302
417
Index
Constitution, causes of disease, and Dopamine agonists, 149 importance of, 150
subfertility, 10–11 DOR. see Decreased ovarian reserve principles of, 150
Consultation, in optimizing patient care, (DOR) poor growth/growth arrest, 283–284
73–75 Dostinex, in ART, 402t causes of, 283–284
Contemplation/worry, and subfertility, 8 Downregulation role of acupuncturist, 284
Contraception clinical issues during ART, 275 quality of, effect of seasons on, 284b
history, optimizing patient care, 74 in Frozen Embryo Transfer, 259 transfer of, activity levels after,
and subfertility, 12 in In Vitro Fertilization (IVF), 237–239 Orthodox medical point of view,
Conventional reproductive medicine pulse during, 239b 170
practice, in male fertility, 5 Du Mai (Governing Vessel), 51 transportation down the female
Corpus albicans, 61 functions of, 51 reproductive tract, 62, 65f
Corpus luteum, 25, 36, 61 vs. Ren Mai and Chong Mai, 52t ’Embryo glue,’ Repeated Implantation
Cortex, 23 Failure and, 303
Corticosteroids, adverse effect on Embryo-maternal interaction, 66
E
fertility, 405t Embryogenesis, 62–65, 63f, 64f, 64t, 65f
Crinone, in ART, 402t E2. see Oestradiol (E2) Embryo’s energy (Pre-Natal Qi), 68–69
Cryptorchidism, 28 Ectopic pregnancy, 62, 322–323, 323b Emergency contraceptive pills, adverse
Culture media conditions, inadequate, signs of possible, 323b effect on fertility, 405t
Repeated Implantation Failure Education, and subfertility, 6 Emotions, and subfertility
and, 305 EFI. see Endometriosis Fertility Index body and spirit, interrelationship
Cultures, and subfertility, 6 (EFI) between, 9
Cyclogest, in ART, 402t EFS. see Empty Follicle Syndrome (EFS) internal causes of disease/injury
Cystic fibrosis gene mutation, 90 Eggs, 32b through, 7–9
in adult human ovaries, 31f Empathic approach, 340
in female foetus and newborn ovaries, Empty Follicle Syndrome (EFS),
D
30f 277–279
Dai Mai (Girdling Vessel), 52 fertilization, 61–62, 63b >36 h between the trigger injection
functions of, 52 immature/no, 277–279 and egg retrieval, 279
Decreased ovarian reserve (DOR), 78 role of acupuncturists in, 279 donor eggs in, 279
Dehydroepiandrosterone (DHEA), for TCM syndromes and, 279 follicular flushing in, 278
poor follicular development, 276 maturation, 61 higher dose/different ’trigger’
Delayed parenthood, as socioeconomic production of, 28–33 medication for, 278
factors, in subfertility, 5–6 in reproductive physiology from TCM and human chorionic gonadotrophin
Depleted ovarian reserve, 189 perspective, 41 (hCG)
Development, from an Orthodox mature, 41f rescue, 279
medical perspective, 12–13 structure of, 30–32, 31f trigger, timing of, 278–279
DHEA. see Dehydroepiandrosterone Egg freezing, for fertility preservation, Empty Heat/Fire, 125
(DHEA) 156b acupuncture treatment of, 125, 126t
Diet, 168–169 Egg retrieval aetiology of, 125
and female fertility, 168 in ART history, 101 pathology and physiology of, 125
inappropriate, and subfertility, 11 before, of menstrual cycle, 220–221 possible consequences for
and male fertility, 168–169 in Gamete Intra-Fallopian Transfer reproduction and ART, 125
Dietary modifications, in polycystic (GIFT), 267 signs and symptoms of, 125
ovary syndrome, 192 trigger injection and, 279 Endocrine investigations, 87–88
Difficult embryo transfer, 284–285 and In Vitro Fertilization (IVF), Endometrial biopsy, 82
complications of, 284 244–245, 245t Endometrial injury, Repeated
role of acupuncturist in, 285 and In Vitro Maturation (IVM), 268 Implantation Failure and, 302
therapeutic options for, 284–285 in Zygote Intrafallopian Transfer Endometrial lining, suboptimal.
Discharge, of pregnant patients, 351, (ZIFT), 267 see Suboptimal endometrial
351t Ejaculation, retrograde, 214 lining
Dizygotic twinning, 296 Ejaculatory ducts, 28 Endometrial thickness, Repeated
risk factors for, 296 Elective single embryo transfer (eSET), Implantation Failure and, 304
DNA damage 296–297, 297t Endometrial tissue, 203
and male factor subfertility, 214 Electroacupuncture (EA), for polycystic Endometriomas, 203
sperm, 90b ovary syndrome, 193 Endometriosis, 82b
DNA fragmentation tests, for sperm, Embryo acupuncture for, 206–207
89–90, 90b, 90t development of. see Embryogenesis referral, 206
Donor ART, 148 grading of, 150–151 diagnosis and staging of, 204
418
Index
419
Index
acupuncture for Ganirelix (Orgalutran ), 238 as key Zangfu organ, 9t, 48–49
preventative treatment, 277 Gate of Life, and connections with and male factor subfertility, 215, 215b
rescue treatment, 277 reproductive organs, 47f pathology, Repeated Implantation
criteria for, 276 General dietary advice, from Traditional Failure and, 308
Orthodox medical preventative Chinese Medicine perspective, 169 syndromes, 116
options, 276–277 General health, medical and fertility Heart Blood Deficiency, 116–118, 118b
Orthodox medical therapeutic options history taking and, 98 acupuncture treatment of, 117, 118t
in affected cycle, 276 Genetic abnormalities, Repeated aetiology of, 116
Follicular flushing, 278 Implantation Failure and, 306 pathology of, 117
Follicular phase, of menstrual cycle, 36 Genetic screening, 82–83, 90–91 possible consequences for
BBT pathology during, 128, 128b, Genetics, and male factor subfertility, 214 reproduction and ART, 117–118
128t, 129t, 130t, 131t Germ cells, 27 signs and symptoms of, 117
menses day 1-5, 219, 221f Gestational carrier, 148–149 Heart Qi Stagnation, 119, 309t
postmenstrual: days 5-14, during adapting treatment principles to, acupuncture treatment of, 119, 119t
stimulation, 219, 222f 266–267 aetiology of, 119
Folliculogenesis, 32–33, 32f, 33b In Vitro Fertilization (IVF), 267 pathology of, 119
®
Follitropin (Gonal-F ), 241, 242t Gestone, in ART, 402t possible consequences for
Fostimon, in ART, 402t GIFT. see Gamete Intra-Fallopian reproduction and ART, 119
Fragmentation, of embryos, 150 Transfer (GIFT) signs and symptoms of, 119
Frozen Embryo Transfer (FET), 146–147, Girdle Vessel (vaginal) discharges, 9 Heart Yin Deficiency, 118–119
258–261 Glucocorticoids, 327 acupuncture treatment of, 119, 119t
controlled, 260 GnRH. see Gonadotrophin releasing aetiology of, 118
embryo transfer, 261 hormone (GnRH) pathology of, 118
acupuncture protocol, 261 Gonadotrophins, 149 possible consequences for
Orthodox medical protocol, 261 longer stimulation of, poor follicular reproduction and ART, 118
follicular stage, 259–260, 261t development and, 276 signs and symptoms of, 118
acupuncture protocol, 260, 260t Gonadotrophin releasing hormone Heat/Fire syndromes, 124–125, 124b
Orthodox medical protocol, (GnRH), 34, 149 acupuncture treatment of, 124–125,
259–260 agonist, 237, 238t 125t
luteal support, 261 long, protocol, 240t aetiology of, 124
acupuncture protocol, 261 short, protocol, 240t Empty, 125
Orthodox medical protocol, 261 analogues, 149–150 foods beneficial in, 170
natural, 259–260 adverse effect on fertility, 405t pathology of, 124
intercourse during, 261b antagonist, 237–238, 238t possible consequences for
ovulation, 260–261 protocol, 240t reproduction and ART, 124
acupuncture protocol, 261 in egg maturation and ovulation, 61 signs and symptoms of, 124
Orthodox medical protocol, pulse pump system Hemizona Assay (HZA), 91–92
260–261 for ovulation disorders, 188 Heparin, low molecular weight,
pretreatment, 259 ovulation induction with, 262 thrombophilia and, 304
acupuncture protocol, 259, 259t suppression with analogues of, 239t Hirsutism, and polycystic ovary
Orthodox medical protocol, 259 Gonal-F, in ART, 402t syndrome, 191, 191b, 195b
Repeated Implantation Failure and, Granulocyte colony stimulating factor History taking, medical and fertility,
303 (G-CSF), 327 from TCM perspective, 97–102
FSH. see Follicle-stimulating hormone Granulosa cells, 23 Hormones, reproductive, 34–35
(FSH) Grief, and subfertility, 8 HOS test. see Hyposmotic Swelling
Fundus, 25 Guilt, and subfertility, 8–9 (HOS) test
420
Index
421
Index
In Vitro Maturation (IVM) (Continued) conversion to, poor follicular pathology, Repeated Implantation
fertilization, 268 development and, 276 Failure and, 307–308
for immature eggs, 279 for endometriosis, 206 syndromes, 109–113
indications for, 147–148 luteal phase, 264 Kidney Deficiency, 47
luteal phase, 269 acupuncture protocol, 264 and endometriosis, 209t
for polycystic ovary syndrome, Orthodox medical protocol, 264 in miscarriages, 318t
192–193 ovulation trigger, 263 Kidney Jing (Essence) Deficiency, 109,
pretreatment, 268 acupuncture protocol, 263 111b, 113b, 309t
stimulation phase, 268 Orthodox medical protocol, 263 acupuncture treatment of, 109, 110t
Inevitable miscarriage, Traditional pretreatment phase, 263 aetiology of, 109
Chinese Medicine management acupuncture protocol, 263 and male factor subfertility, 215
of, 317 Orthodox medical protocol, 263 pathology of, 109
Infections stimulation phase, 263 potential consequences for
as cause of miscarriage, 313–314 acupuncture protocol, 263 reproduction and ART, 109
and male factor subfertility, 214 Orthodox medical protocol, 263 signs and symptoms of, 109
Repeated Implantation Failure and, vs. IVF, 145f Kidney Yang Deficiency, 111–113, 113b,
304 Intravenous immune globulin (IVIG), 307–308, 309t
screening of, 85, 91 326 acupuncture treatment of, 112–113,
Infertility versus acupuncture, 328b 112t
see also Subfertility Iodine, 396 aetiology of, 111–112
female, associations between some and female fertility, 167, 167b with Damp-Phlegm, and polycystic
microbiological agents and and thyroid disease, 200 ovary syndrome, 194t
anatomical location of, 86t Iron, 397 pathology of, 112
male, associations between some and female fertility, 167 potential consequences for
microbiological agents and, 91t Irregular cycle syndromes, 220f reproduction and ART, 112
and maternal weight, 161 Isthmus, 23–25 signs and symptoms of, 112
and paternal weight, 162 IUI. see Intrauterine Insemination (IUI) Kidney Yin Deficiency, 109–111, 111b,
prevalence of, 3 IVF. see In Vitro Fertilization (IVF) 309t
secondary, Orthodox medical IVIG. see Intravenous immune globulin acupuncture treatment of, 111, 111t
management of, 212 (IVIG) aetiology of, 110
tests and investigations, 76b IVM. see In Vitro Maturation (IVM) pathology of, 110
treatment of, 3 and polycystic ovary syndrome, 194t
trends, 3 potential consequences for
J
Infertility disorder reproduction and ART, 111
definition of, 2–3, 2t Jing (Essence) signs and symptoms of, 110–111
implications of, 2–3 characteristics of, 41
Inflammation, and male factor relationships between Blood, Qi, Body L
subfertility, 214 Fluids, and, 40f
Inhibin, 35 in reproductive physiology from TCM Lactobacillus acidophilus, in vagina, 25
Inhibin B, 80 perspective, 39–41 Laparoscopic Electrocoagulation of the
Insulin-sensitising drugs, 149 types of, 40 Ovaries (LEO), indications for,
Interval (sequential) embryo transfer, Jing (Essence) Deficiency syndromes, 189
Repeated Implantation Failure foods beneficial in, 169–170 Laparoscopy, 81–82
and, 302 Leukocyte Antibody Detection (LAD)
Intracytoplasmic Morphologically K test, 326
Selected Sperm Injection (IMSI), Leukocytes
12–13, 153–154, 305–306 Karyotyping, 90 in sperm transportation, 60
Intracytoplasmic Sperm Injection (ICSI), Key Zangfu organs test of, in semen, 88–89
12–13, 153, 154f, 245–246, 282 and associated characteristics, 9t Leukospermia, 87t
for endometriosis, 206 in fertility and early pregnancy, 45–50 Leydig cells, 27
fertilization failure in, 282, 283t relationships between Extraordinary LH. see Luteinising hormone (LH)
indications for, 154t Vessels, Uterus, and, in Lifestyle
Intralipid therapy, 326–327 reproduction, 48f and male factor subfertility, 213, 217
Intrauterine Insemination (IUI), 144 and In Vitro Fertilization (IVF), 50 modifiable, in medical and fertility
adapting treatment principles to, Kidney history taking, 100
263–264 functions of, 45–46 modifications, in polycystic ovary
acupuncture protocol, 264 as key Zangfu organ, 9t, 45–47 syndrome, 192
Orthodox medical protocol, 264 and male factor subfertility, 215 negative, and subfertility, 7
422
Index
and Repeated Implantation Failure, Luteinising hormone (LH), 34–35, 78 and miscarriages, 162
307 high levels of, 61 Medical history
and thyroid diseases, 200 ovulation predictor kits, 176 managing the patient with a complex,
LIT. see Lymphocyte Immunization reference ranges for, 77t 301–338
Therapy (LIT) Luteinising hormone releasing hormone optimizing patient care, male, 74
Liver (LHRH) past, 99
functions of, 47–48 for ovulation disorders, 188 Medical tests, and investigations, 99
as key Zangfu organ, 9t, 47–48 pulse pump system, ovulation Medication, 164–165
and male factor subfertility, 215 induction with, 262 effect on female fertility, 164
pathology, Repeated Implantation Lutrepulse, in ART, 402t effect on male fertility, 164–165
Failure and, 308 Luveris, in ART, 402t recommendation for management of,
syndromes, 113–116 Lymphocyte Immunization Therapy 165
Liver Blood Deficiency, 111b, 113–115, (LIT), 327 that affects reproduction, 165b
115b, 309t Medulla, 23
acupuncture treatment of, 114–115, Menarche, in reproductive physiology
M
114t from TCM perspective, 42
aetiology of, 113 Magnetic resonance imaging (MRI), 82 Menopur, in ART, 402t
®
pathology of, 113 Male factor hormone, assessment of, 88t Menotrophin (Merional ), 241, 242t
and polycystic ovary syndrome, 194t interpretation of, 389t Menstrual blood, conjectural
potential consequences for Male factor subfertility, 5f, 213–217, composition from TCM point of
reproduction and ART, 114 217b view, 43f
signs and symptoms of, 113–114 acupuncture for, 218f Menstrual cycle, 35–37
Liver Blood Stasis, 116 ASRM interpretation of ultrasound effect of thyroid disease on, 198–199
acupuncture treatment of, 116, 117t examination of, 390t follicular phase of
aetiology of, 116 clinical perspective of, 215–217 menses day 1-5, 219, 221f
and endometriosis, 209t effect on conception and ART postmenstrual: days 5-14, during
pathology of, 116 outcomes, 214 stimulation, 219, 222f
possible consequences for importance of treating men in, irregularities in, 221f, 222f, 224f
reproduction and ART, 116 215–217 luteal phase (days 16-28), 222–223,
signs and symptoms of, 116 and infections, 214 224f
Liver Qi Stagnation, 115–116, 116b, 294 investigations of, 213 in medical and fertility history taking,
acupuncture treatment of, 115–116, length of treatment in, 217 98
115t lifestyle factors of, 213, 217 ovulation (days 14-16) or before egg
aetiology of, 115 markers of, 217 retrieval, 220–221, 223f
and endometriosis, 209t medical causes of, 213 phases of, 35
pathology of, 115 Orthodox medical management of, regularity of, 219, 220f
potential consequences for 213–214 regulation of
reproduction and ART, 115 research on acupuncture and, 215 with acupuncture, 218–223
signs and symptoms of, 115 TCM in classical TCM, 218b
Local anaesthetics, adverse effect on pathophysiology, 214–215 importance of, 218
fertility, 405t syndromes and, 215, 216t principles of, 218–219
Lovenox, in ART, 402t unexplained, 214 in reproductive physiology from TCM
Low molecular weight heparin, Male fertility, effect of thyroid disease on, perspective, 42–43
thrombophilia and, 304 199–200 four phases of, 43–45, 44t
Lung Male reproductive system variations in length of, 36f
functions of, 49 abnormalities of, 28 Menstrual discharge, in reproductive
as key Zangfu organ, 9t, 49–50 anatomy of, 27–28, 27f physiology from TCM
Lupus anticoagulant syndrome. main functions of, 27 perspective, 42
see Antiphospholipid syndrome Maternal age, Repeated Implantation Menstrual history, optimizing patient
(APS) Failure and, 304–305 care, 73
Luteal/endometrial support medication, Maternal complications, in multiple- Mental-emotional health, and polycystic
150 gestation pregnancy, 296 ovary syndromes, 191
Luteal phase, of menstrual cycle, 36–37 Maternal influences, and poor embryo Merional, in ART, 402t
BBT pathology during, 132–134, 132t, growth, 283–284 Metformin
133t, 134t, 135t Maternal weight, 161–162 in ART, 402t
(days 16-28), 222–223, 224f and ART, 161–162 for polycystic ovary syndrome, 192
deficiency, 132 and comorbidities, 161 Methadone, adverse effect on fertility,
Luteal phase insufficiency, 314 and infertility, 161 405t
423
Index
Metoclopramide, adverse effect on maternal complications in, 296 Omega 3, 396, 398
fertility, 405t risks associated with, following ART, and female fertility, 167, 167b
Micronutrients 296 male fertility, 168
and female fertility, 166–167 Mutuality Oocyte. see Egg
and male fertility, 168 return to, 341–342 Oogenesis, 30
Mid-cycle spotting/bleeding, 220b for therapeutic relationship in Oogonia, 30
Mingmen, essential for conception, 68 acupuncture practice, 339–340 Orgalutran, in ART, 402t
Miscarriages, 310–325 Myometrium, 25 ’Ovarian drilling,’, 189
causes of, 312–315 Ovarian factors, in female reproductive
anatomical factors, 312–313 abnormalities, 25
N
embryo genetic abnormalities/ Ovarian follicles, 23
®
parental age, 312 Nafarelin (Synarel ), 237 Ovarian Hyper-Stimulation Syndrome
endocrine factors, 314 Natural conception, from TCM point of (OHSS), 239–241, 291–295,
environmental, lifestyle, and view, 67–68 295b
nutritional factors, 315 Natural cycle, indications for algorithm of acupuncture
immunological factors, 315 Intrauterine Insemination (IUI) management of, 293f, 294–295
infections, 313–314, 314b in, 144 classifications of, 292t
male factor, 315 Natural fertilization (in vivo), vs. ART human chorionic gonadotropin and,
parental genetic abnormalities, 312 fertilization (in vitro), 62, 63t 292
diagnostic classifications of, 316t Necrozoospermia, 87t metformin role in prevention of, 192
management of patients experiencing NICE, infertility definition, 2t mild, 291
anxiety about, 322 NK cells Orthodox medical management of,
and maternal weight, 162 acupuncture and, 328 291–294
missed, 312 assay, reference values of, 391t patient management, 293f, 294–295,
Orthodox management of patients Non-invasive embryo assessment, 295b
presenting with suspected, Repeated Implantation Failure severe, 291
315–316, 315b and, 306 signs and symptoms of, 292t
and paternal weight, 162 Non-steroidal anti-inflammatory drugs, Traditional Chinese Medicine view of,
and polycystic ovary syndromes, 191 adverse effect on fertility, 405t 294
recurrent, 312 Normogonadotrophic Ovarian reserve
spontaneous clinical, 312, 313f normooestrogenic anovulation, decreased, 78
spontaneous preclinical, 312, 313f 189t depleted, 189
and subfertility, 11 Nuclear genome transfer, 156 effect of thyroid disease on, 198
TCM syndromes in, 318t Nutrition and polycystic ovary syndromes, 191
threatened, 320f, 322b in optimizing female fertility, 396 screening, 78–80
Traditional Chinese Medicine lifestyle in optimizing male fertility, 398 AFC, 80t
advice in prevention of, 321 and subfertility, 7 AMH, 79t
diet, 321 Ovaries, 23
physical activity, 321 O Overexertion, and subfertility, 11
Missed miscarriage, 312 Ovitrelle, in ART, 402t
Traditional Chinese Medicine Obesity, 161 Ovulation, 23, 36, 37f, 61, 63b
management of, 317 Obstetric history, 99–100 assessment of, 76–77, 76t
Mitochondria replacement techniques, optimizing patient care, 74 (days 14-16), 220–221, 223f
156 Occupational factors, effect on detection methods, 175–177
Monochorionic twins, 296 reproductive health, 165–166 in Frozen Embryo Transfer, 260–261
Monophasic pattern, BBT chart, 128 Oestradiol (E2), 78 induction. see Ovulation induction
Monozygotic twinning, 296 reference ranges for, 77t natural cycle vs. ART cycle, 63t, 146t
Morula stage, 62 Oestrogens, 35, 150 Ovulation induction, 143–144,
Motile Sperm Organelles Morphology OHSS. see Ovarian Hyper-Stimulation 261–263
Examination (MSOME), 89 Syndrome (OHSS) acupuncture protocol, 262–263
MRI. see Magnetic resonance imaging Oligoasthenoteratozoospermia, 87t final egg maturation/ovulation
(MRI) Oligoasthenozoospermia, 87t trigger, 262–263
MSOME. see Motile Sperm Organelles Oligomenorrhoea, 188 follicular (stimulation) phase, 262
Morphology Examination as predictors of polycystic ovary luteal phase, 263
(MSOME) syndrome, 191 pretreatment cycle, 262
Mucus, 59 Oligospermia, 87t final egg maturation and, in In Vitro
Multiple-gestation pregnancy, 291, severe, 87t Fertilization (IVF), 244, 244t
296–299 Oligoteratozoospermia, 87t follicular phase, 262
424
Index
425
Index
426
Index
Semen analysis, 86–87 Sperm retrieval methods, 153 Traditional Chinese Medicine view of,
WHO interpretation of, 87t, 388t Spermatids, 28 172–173
Seminal vesicles, 28 Spermatocytes, primary, 28 Subfecundity, 3
Seminiferous tubules, 27 Spermatogenesis, 28, 29f Subfertility, 1–22
Septate uterus, 26 Spermatogonia, 28 see also Infertility
Serophene, in ART, 402t Spermatozoon, structure of, 29f causes of
Sexual arousal, 59 Spermiogenesis, 28, 29f in acupuncture practice, 4
Sexual history, optimizing patient Spleen from an Orthodox medical point of
care, 74 functions of, 49 view, 3–5, 4f, 5f
Sexual intercourse, 59–60, 173–175 as key Zangfu organ, 9t, 49 from TCM point of view, 7–12
frequency of, 173–174, 174f and male factor subfertility, 215 causes of diseases in, 12
in optimizing female fertility, 397 pathology, Repeated Implantation common syndromes in, contemporary
in optimizing male fertility, 398–399 Failure and, 308 TCM literature, 108–109
recommendation for management of, syndromes, 119–121 contributory factors of, in Orthodox
177 Spleen and Stomach Qi Deficiency, medical perspective, 5–7
and subfertility, 7, 12 120–121, 121b environmental factors as, 6
timing of, 16 acupuncture treatment of, 121, 121t occupational factors as, 6–7
fertile window and, 173, 174f aetiology of, 120 socioeconomic factors as, 5–6
Traditional Chinese Medicine view of, pathophysiology of, 120 effects of, on patients, 342
177 possible consequences for fallopian tubal factor and, 25
Sexually transmitted infections, and reproduction and ART, 121 Jing-Shen examination in, 102–103
subfertility, 7 signs and symptoms of, 120–121 pathology in female, 108
Shen (Spirit), 69, 69f, 119 Spleen Qi Deficiency, 119–120, 309t to pregnancy, transition from, 348–351
affected, and RIF treatment, 309t acupuncture treatment of, 120, 120t secondary. see Secondary subfertility
SIS. see Saline infusion sonography (SIS) aetiology of, 119–120 and sexual intercourse, 7, 12
Sleep pathology of, 120 from TCM perspective
and female fertility, Orthodox medical possible consequences for abdominal diagnosis in, 106–107,
point of view, 170 reproduction and ART, 120 107f
from Traditional Chinese Medicine signs and symptoms of, 120 five phases examination in, 103
perspective, 171 Spontaneous clinical miscarriage, 312, pulse diagnosis in, 103, 103b, 105t
Smoking, 162–163 313f syndromes diagnosis in, 108–125
effects on reproductive health, Spontaneous preclinical miscarriage, tongue diagnosis in, 104–106, 106f
162–163 312, 313f treatment of, in male and female
in optimizing female fertility, 395 Stagnation, 111b partners, 4–5
in optimizing male fertility, 397 and polycystic ovary syndrome, 194t unexplained, 175b
recommendation for management of, Sterility, 3 Suboptimal endometrial lining, 279–281
163 Steroids, anabolic, adverse effect on causes and therapeutic
Traditional Chinese Medicine view of, fertility, 405t options, 280
163 Stimulated cycle, Intrauterine lifestyle advice and, 280
Sonohysterography (saline infusion Insemination (IUI) in, 144 role of acupuncturist in, 280–281
sonography (SIS)), 81 Stimulation medication, increasing dose Subseptate uterus, 26
Sperm, 28–33, 29f, 30b, 60 of, in poor follicular Supplements
DNA development, 276 in optimizing female fertility, 396–397
damage, 90b Stomach in optimizing male fertility, 398
fragmentation tests, 89–90, 90b, 90t functions of, 49 Suppression
hyperactivation of, 61 as key Zangfu organ, 49 in Frozen Embryo Transfer, 259
no, 281, 281b and male factor subfertility, 215 in In Vitro Fertilization (IVF), 237–239
role of acupuncturist, 281 syndromes, 119–121 with gonadotrophin releasing
prefertilization changes of, 60–61 Stress, 171–173 hormone (GnRH) analogues,
in reproductive physiology from TCM as cause of infertility, 171 239t
perspective, 41–42 effects of, on reproductive system, Suprefact, in ART, 402t
mature, 42f 172 Surgery
structure of, 28–30 levels, increased, and subfertility, 7 for endometriosis, 205–206
transportation of, up the female and male factor subfertility, 215, 215b for polycystic ovary syndrome, 192
reproductive tract, 60, 61b in optimizing female fertility, 397 and subfertility, 11
Sperm DNA test, interpretation of, 390t in optimizing male fertility, 398 Surrogacy, 148–149
Sperm duct. see Vas deferens prevalence of, in ART patients, 172 adapting treatment principles to,
Sperm penetration assay, 91 tips to reduce, 172, 172b 266–267
427
Index
428
Index
429