Original article title: The Application of Traditional Chinese Medicine with Assisted Reproductive Technologies
Abstract
There is growing evidence that using traditional Chinese medicine in conjunction with Western reproductive treatments results in higher pregnancy rates. This paper discusses research that has been conducted using acupuncture during various parts of in vitro fertilization cycles, as well as the results of these studies. Applications of these studies in the form of treatment plans are given to two common patient populations seen in acupuncture clinics: women who are already engaged in a medicated cycle, and women who are preparing for a future cycle. Descriptions of Western treatment approaches are also described in addition to biomedical considerations when working with fertility patients.
INTRODUCTION
The positive role of traditional Chinese medicine (TCM) in treating women’s infertility is becoming more evident as research continues in this field. In reviewing the literature on this topic, it is apparent that the inclusion of Chinese medicine, acupuncture in particular, in an Assisted Reproductive Technology (ART) treatment protocol, increases the likelihood of a positive pregnancy test. The results of a study by Gillerman[1] show that “that rates of live birth and positive pregnancy tests are significantly higher following a consensus acupuncture protocol for women undergoing IVF treatment compared with a control group”. In this clinical trial the study group received three additional acupuncture treatments before the standard two treatments on embryo transfer day. The control group only received two embryo transfer day treatments. The results showed the study group had a 42% positive pregnancy rate compared to the control groups 15.94% positive rate.[1] The point protocols used in this study were created by a consensus of 15 international acupuncturists who work primarily with women undergoing IVF treatments.
In a similar study of acupuncture’s effect on IVF cycle outcomes by Guven,2 the study group received three acupuncture treatments the week of the embryo transfer, whereas the control group never received acupuncture. The results of this study showed a positive pregnancy test in 63.9% of the study group and only 33.3% of the control group.[2] This study also concluded that the inclusion of acupuncture treatments, especially leading up to embryo transfer day, produce higher rates of pregnancy in the patients studied.
It is important to note that in both reviewed studies inclusion criteria required women to be using their own eggs, and not donor eggs. In addition, the Guven study included women with unexplained infertility as the primary diagnosis for infertility in the patient population, whereas the Gillerman study did not discuss the infertility diagnosis of its participants.
CHINESE MEDICAL THEORY
There are three main meridian systems, or energy pathways, that are involved in the proper function of a woman’s reproductive system: the Liver, Spleen, and Kidneys. If there are any disruptions in the relationship of these meridians, fertility problems could result. In an TCM fertility theory article, the author describes the Kidneys as the origin of yin-yang balance and how external factors can affect this balance. In addition Zhao[3] states, “long term intake of oral contraceptive pills may suppress the Kidney qi, or repeated use of IVF/ACT drugs interfere with Kidney function, which may lead to delayed periods, scanty periods, anovulation or even amenorrhea and infertility”.
The Spleen meridian is the source of qi and blood. It is responsible for how we use the food and nutrients we put into our body to make this qi and blood and therefore how it flows in our body. Zhao describes what can cause disturbances in our Spleen meridian as follows: “Dysfunction of the spleen may cause accumulation of dampness, qi and blood deficiency, leading to scanty or heavy periods, short menstrual cycles, spotting or bleeding after ovulation, short luteal phase and infertility”.[3]
Lastly, The Liver meridian governs the flow of qi, how we store our blood, and how we regulate the volume of blood in circulation in our bodies. It also has a large role in healthy ovulation as this process requires strong, unencumbered qi movement in the ovaries. Zhao describes the Liver’s role in reproductive health in the following way,[3] “Repeated and persistent emotional abnormality may result in the stagnation of Liver qi or hyperactivity of Liver yang, causing oestrogen to build up, leading to heavy and painful periods, short menstrual cycles, or the uterus becoming a toxic environment, hostile to implantation and conception.” Any combination of these meridians showing dysfunction can help explain why a woman may be experiencing infertility. Understanding these pathways and their functions can help one see that the side effects of women receiving ART therapies may see an increase in dysfunction of these systems.
TREATMENT PLANS
While the foundation of TCM is to provide a diagnosis and treatment plan based on each patient’s case, there are basic protocols that can be built upon and individualized. The two most common scenarios presented in clinics are women currently undergoing IVF treatments and women preparing to start an upcoming IVF cycle. The following are treatment plans addressing each scenario.
Treatment Plan for women currently taking IVF medications:
Acupuncture is primarily used while women are in a current IVF cycle. In this treatment plan, the women are typically using ovarian stimulation medications when they begin seeing an acupuncturist. Therefore, the acupuncture points used help support the growth of follicles by encouraging blood flow to the ovaries and uterus, and to reduce stress levels in the body. These points include St 29 guilai, CV 4 guanyuan, CV 6 qihai, Sp 6 sanyinjiao, Sp 10 xuehai and any additional points that support the patient’s constitution, or baseline health condition. The patient should come in for a minimum of two treatments during the stimulation period of the cycle and add in additional treatments if the follicular growth is slow or delayed. After the egg retrieval, the patient will return for two treatments on embryo transfer day. The following points are used shortly before the embryo transfer: Sp 8 diji, Sp 10 xuehai, Liv 3 taichong, St 29 guilai, CV 4 guanyuan, and H 7 shenmen or yintang, according to the Delphi consensus.[1] Directly following the embryo transfer procedure, the patient should be needled with the points GV 20 baihui, K 3 taixi, St 36 zusanli, Sp 6 sanyinjiao, P 6 neiguan, and shenmen (auricular). While there isn’t much evidence of the benefit of acupuncture in the 9-10 days before the patient receives her first beta HCG test, acupuncture can help relax the patient during this stressful waiting period.
Herbal formulas are not used while a patient is taking IVF medications. There is not much evidence to support the use of herbs at this time, nor are there reports of the positive or negative personal effects of herbs with concurrent use of IVF medications. Lifestyle suggestions include encouraging patients to try and reduce the amount of external stressors during their cycle, as well as reducing intensity of exercise or other activities that overwork the body.
Treatment plan for women preparing for an upcoming IVF cycle:
It is best to start this plan three months prior to the start of IVF medications as the growth phase for an egg in preparation for ovulation is around 90 days.[4] Starting this early helps to benefit the eggs that will be stimulated in the IVF cycle. As the patient is not on medications during this time period, Chinese herbs can be used to help prepare the ovaries and uterus for the upcoming cycle. According to TCM fertility specialist Jane Lyttleton,[5] this modified version of the formula Gui Shao Di Huang Wan (Angelica, Peony and Rehmannia Decoction) can be used daily in the time leading up to the start of medications: shu di huang (Rehmanniae Radix Preparata) 12g, shan yao (Dioscoreae Rhizoma) 9g, shan zhu yu (Corni Fructus) 9g, fu ling (Poria) 9g, mu dan pi (Moutan Cortex) 9g, ze xie (Alismatis Rhizoma) 6g, dang gui (Angelicae Sinensis Radix) 9g, bai shao (Paeoniae Radix Alba) 9g, dan shen (Salviae Militiorrhizae Radix) 9g, sha ren (Amomi Fructus) 6g, tu si zi (Cuscutae Semen) 9g, xiang fu (Cyperi Rhizome) 6g, he huan pi (Albiziae Cortex) 9g, and lu jiao sheng (Cornu Cervi Degelatinatium) 6g. Patients should take this dosage of raw herbs daily leading up to their medication start date. Alternatively, this formula can be compounded in granular form making dosage adjustments based on the herbal concentrations values of the chosen brand.
According to Lyttleton,[5] acupuncture treatments should be done weekly utilizing the following points to support the Kidneys, blood, Ren and Chong vessels: CV 7 yinjiao, K 5 shuiquan, K 13 qixue, K 3 taixi, K 6 zhaohai, Sp 6 sanyinjiao, St 36 zusanli, Liv 3 taichong, P 6 neiguan, St 29 guilai, GV 20 baihui. In addition to these points, the practitioner should include points that treat the individual patient’s constitutional diagnosis. Leading up to the IVF cycle, each menses should be evaluated to see if there are changes in symptoms including menstrual cramps, PMS, thickness of the blood flow, clotting, and volume of menstrual blood, as well as cervical mucus before and at ovulation. Practitioners should make additions to the point protocol to reflect any changes seen in the cycle. Once the medication for IVF begins, discontinue the herbs and follow the treatment plan above for “women currently taking IVF medication”.
It is important to consider each patient’s ability to adhere to the treatment protocols. For instance, not every patient may be open to taking herbs before starting medications. In this case, the addition of moxibustion at the Kidney and Spleen points during acupuncture treatment can be helpful in boosting the function of these points in lieu of herbs. The patient can also be taught how to do moxa at home after guidance from their acupuncturist. Other considerations include patients being unable to receive acupuncture treatments weekly due to time or money constraints. In this case, encourage patients to do what they can do without inducing too much stress. Offering ear seeds to take home on specific acupuncture points can help patients space out treatments as well.
PROGNOSIS
Each patient’s response to TCM varies, so the best way to provide prognosis is through clinic examples. Below are a couple clinical cases that integrate both TCM and ART over different timelines.
Clinical Case 1:
The patient is a 37-year-old female who is an avid runner, constantly training for marathons. She experiences fatigue from running daily and not sleeping well due to her three young boys under the age of five waking her up most nights. She is always cold and reports that she only sweats when she trains. Her digestion is very sluggish most likely as a result of her raw food diet, and she often is bloated. She craves sweets but does not allow herself to indulge, except for donuts, as she is a Dentist and takes great care of her teeth. She frequently drinks room temperature water and avoids iced drinks. The patient is very calm and kind and does not seem to dwell on things that bother her. She uses her running to work through her life stressors. All symptoms associated with her head are within normal limits. Her bowel movements are always first thing in the morning and tend to be looser and sometimes watery. The patient experiences light periods lasting only three days with cramping on cycle day one. She also experiences lots of lower back pain during menses and complains that this is her most significant menstrual symptom. Her tongue was swollen with scalloped edges. Her pulse was slippery in the right guan position and deep in the right chi position.
Her fertility history is significant. She came to the clinic trying to conceive after having two successful pregnancies from IUI resulting in a set of twins and a single child. Her pregnancy with twins was difficult – she was hospitalized for the last three months of her pregnancy with placenta previa, and the twins were delivered early at 30 weeks. Two years later, she came to the acupuncture clinic after two failed rounds of IVF that gave her zero viable embryos. After reviewing her medical history, she was diagnosed with Spleen qi deficiency and Kidney yang deficiency. The patient was advised to postpone her next IVF cycle until there were improvements in her symptoms in order to properly prepare her for a future IVF cycle. She agreed to this and took a six-month break from ART treatments.
During this break, the patient received weekly acupuncture treatments including, but not limited to, the following points: St 36 zusanli, Sp 3 taibai, Sp 6 sanyinjiao, K 3 taixi, K 7 fuliu, yintang, shenmen (auricular), CV 4 guanyuan, CV 6 qihai, St 29 guilai, and Lu 7 lieque. Moxibustion was used on Sp 3 taibai, St 36 zusanli, K 3 taixi almost weekly, using ibuki stick-on moxa. These points were chosen to treat the patient’s constitutional diagnosis and to open up the Ren channel in accordance to Lyttleton.[5] The patient took Chinese granular herbs daily in the above-mentioned formula Gui Shao di Huang Wan (Angelica, Peony and Rehmannia Decoction). She was advised to avoid raw foods and to eat warm, cooked foods and to reduce her level of running significantly. The patient complied and reported switching from eating salads to stir fry and soups and she started drinking ginger tea before her meals. Additionally, she only would go running if her energy levels were high and she didn’t feel the need to consume caffeine first to supplement her energy.
Over the six months of preparation, the patient reported heavier periods, reduced low back pain, increased energy levels, and an overall better mood. We did not have any blood work during this time to compare to her last IVF cycle. She discontinued her herbs and kept up with acupuncture as she entered her IVF cycle and saw improved results. From one cycle on the same medication protocol as 6 months prior, she got six genetically normal and healthy embryos. She transferred two of the embryos, fell pregnant with twins, and delivered two healthy 8 lbs babies at 38 weeks. This patient used TCM for six months and had a completely different twin pregnancy experience as a result.
Clinical Case 2:
This patient is a 32-year-old who experiences moderate levels of anxiety on a daily basis. She worries about most things, can get easily worked up about small issues and frequently states that she is “always stressed out”. She does not sleep well as she wakes up nearly every night with night sweats that soak her clothing. While she is hot at night, she complains of being cold throughout the day. She struggles with hyperthyroidism even though she takes daily thyroid medication. Her physician checks her levels every three months and has found that her levels of TSH can range from .31 to .65 mIU/L. Her energy level is lower than average likely due to her frequent waking up at night. She does not complain of digestive issues other than some heartburn and her appetite is within normal limits. She tends towards constipation and experiences frequent urination. Rarely she will get headaches, though they tend to occur prior to the onset of menses as part of her intense PMS. She experiences cramping the first few days of her period and a heavy flow without clots. Her tongue is red with a thin coat and a few horizontal cracks. Her pulse is thin and weak on the left chi position and wiry on the left guan.
The patient was trying to conceive for two years and had two unsuccessful IVF cycles that resulted in one embryo each and neither embryo transfer produced a pregnancy. Her Western diagnosis was idiopathic infertility. After reviewing her complete medical history, her TCM diagnosis was Kidney yin deficiency with empty heat as well as Liver qi stagnation. She declined herbs, as she was only a month from starting a new IVF cycle, so her treatments consisted primarily of weekly acupuncture. The points that were used, depending on the time of her cycle, included K 7 fuliu, H 6 shenmen, Liv 3 taichong, LI 4 hegu, Zigongxue, K 6 zhaohai, CV 6 qihai, Sp 6 sanyinjiao, yintang, GV 20 baihui. These points were chosen based on her constitutional diagnosis and focused on nourishing Kidney yin, moving Liver qi, and calming the Shen. After her first two treatments, the patient reported a reduction in both the severity and frequency of her night sweats. She only needed to change her sweat-soaked clothes one time in the second week which was an improvement from four-to-six times a week before acupuncture treatments began. Additionally, she reported feeling calmer after two treatments despite being closer to the start of her next IVF retrieval cycle.
Once starting IVF, she successfully retrieved 16 eggs, and received news of five healthy embryos. As she prepared for her frozen embryo transfer, she came in for twice a week acupuncture as she was very nervous about the procedure and pending results. She learned she was pregnant and continued with weekly acupuncture treatments throughout her pregnancy to help manage her stress levels. She delivered a 9lbs 4oz baby boy at 40 weeks and has since delivered a second 9lbs boy after another successful embryo transfer using acupuncture as well. This patient only used TCM for a month before starting her IVF cycle and found success. Her age did not seem to affect her success which leads to the thought that stress levels could have been a contributing factor to her idiopathic infertility diagnosis.
CONCLUSION
Working with women going through fertility treatments for the past six years, I have seen numerous successful pregnancies and births. Finding scientific research that shares the same conclusions that I see in clinical practice provides validity for combining both modalities. When there is research supported information available, the credibility of acupuncture grows. This research is a tool to inform patients, acupuncturists, and Reproductive Endocrinologists of the benefits of including acupuncture in patient treatment plans. It also includes frequency, dosage and timing of treatments and herbs which are details that are not often detailed thoroughly in publications.
REFERENCES
- Gillerman K, Kulkarni A, Shah A, et al. The impact of acupuncture on IVF success rates: A randomised controlled trial. Fertility Science and Research. 2018;5(2):48-54. http://doi.org/10.4103/fsr.fsr_37_18. Assessed November 12, 2020.
2. Guven PG, Cayir Y, Boreckci B. Effectiveness of acupuncture on pregnancy success rates for
women undergoing in vitro fertilization: A randomized controlled. Taiwan J Obstet Gynecol. 2020;59(2):282-286. https://doi.org/10.1016/j.tjog.2020.01.018. Assessed November 13, 2020.
3. Zhao L. Treating Infertility by the Integration of Traditional Chinese Medicine and Assisted Conception Therapy. Journal of the Association of Traditional Chinese Medicine. 2011;18(2):7-11.
4. Jennings T. Improving Egg Quality. Conceive Baby. September 17, 2017. Accessed July 1, 2021. http://conceivebaby.com.au/improving-egg-quality/
5. Lyttleton J. Treatment of Infertility with Chinese Medicine. 2nd ed. Churchill Livingston Elsevier; 2013.
