Original title: Achieving Natural Pregnancy with Acupuncture, Herbs, and Moxibustion in a Patient with Polycystic Ovarian Syndrome: A Case Report
ABSTRACT
This case presents the use of traditional Chinese medicine (TCM), including acupuncture, moxibustion, and Chinese herbal formulas, to treat a 34-year old female with polycystic ovarian syndrome (PCOS) for infertility. After trying to conceive unsuccessfully for more than 12 months, it was recommended that the patient try in vitro fertilization to conceive. She did not want to undergo an invasive procedure and decided to try TCM. The patient received weekly acupuncture treatment with moxibustion and Chinese herbal therapy over the course of five months, from late 2019 until early 2020. She conceived in early 2020 and carried a healthy pregnancy to term. This case suggests that in patients diagnosed with PCOS related infertility for whom in vitro fertilization is not possible or not desired, TCM may provide an alternative path to conception and pregnancy.
INTRODUCTION
Polycystic ovarian syndrome (PCOS) is one of the most common female endocrine disorders and is thought to affect 3%-10% of women.[1] Infertility and fertility hormone treatments are significantly higher in women who report PCOS.[2] In the most common presentation of PCOS, insulin-resistant PCOS, higher levels of circulating insulin leads to decreased levels of sex hormone binding globulin, and therefore higher levels of free testosterone. Although the exact mechanism is not yet clear, these excess levels of androgens appear to affect fertility. In many patients, high levels of free testosterone appear to arrest ovarian follicles in the antral stage, leading to chronic anovulation.[3] Patients with PCOS who experience infertility may seek integrative health therapies such as traditional Chinese medicine instead of, or in addition to, medical fertility treatments such as metformin, hormone therapy, and/or or in vitro fertilization (IVF).
In the United States, most acupuncturists are trained in traditional Chinese medicine (TCM), which includes the practice of acupuncture, Chinese herbs, moxibustion, nutritional therapy, bodywork and lifestyle recommendations. Despite the prevalence of TCM in clinical practice, most research focuses on acupuncture as a stand-alone intervention. To date, there is only one study and one case report published in English in peer reviewed literature on the use of whole systems TCM in the treatment of infertility, highlighting the need for further published literature on the efficacy of TCM treatments beyond acupuncture alone.[4, 5]
This case report details the use of TCM treatment, including acupuncture, herbal medicine, and moxibustion, and the reproductive outcome in a patient with PCOS who had not conceived for over a year despite ultrasound confirmation of ovulation.
CASE HISTORY
A 34-year old female presented with primary infertility in late 2019. During her initial visit, she reported surgery to repair a septate uterus several years before, and that she and her husband had been trying to conceive for over a year. The patient had been diagnosed with insulin-resistant PCOS and reported menstrual irregularities including mid-cycle bleeding that ranged from spotting to heavy flow. It had been suggested to the patient that her best chance for conception would be through in vitro fertilization (IVF). She decided to try acupuncture and herbal medicine for fertility because she felt that she was not ready to put herself through an IVF cycle.
The patient experienced regular menstruation, with a cycle length of 24-28 days. She reported a typical period as 4-5 days (but up to a week long) with heavy flow. Her menstrual blood was dark red to fresh red with some larger clots. She experienced intermittent menstrual flooding during her period with increasing frequency over recent months, occasionally necessitating clothing changes. She reported some cramping and slight PMS symptoms, primarily bloating, food cravings, and some moodiness. During her most recent cycles, ovulation was confirmed by ultrasound at her gynecologist’s office, occurring between CD12-14. At the time of intake, the patient expected her period to arrive within a few days. She had not tried to conceive during that month, as her midcycle bleeding had been particularly heavy.
In addition, the patient reported lifelong fatigue, despite sleeping up to 10 hours per night. She slept solidly through the night, but did not typically feel rested on waking. The patient tended to feel cold, although she occasionally experienced night sweats and hot flashes. She experienced regular issues with digestion, including bloating, diarrhea, and gas. She reported frequent anxiety and elevated levels of perceived stress. The patient experienced chronic neck and upper back tension and pain along the gallbladder meridian. The patient denied any issues with urination. Her cholesterol levels were slightly elevated, but she reported an otherwise unremarkable cardiovascular health history.
The patient’s pulses were wiry in the cun and guan positions and weak and deep in the chi position bilaterally. Her tongue was pale and puffy with a thin, white, wet coat. The sides of her tongue were scalloped and slightly dusky.
TRADITIONAL CHINESE MEDICINE DIAGNOSIS
This patient’s diagnosis was one of mixed deficiency and excess. She presented with Liver qi stagnation, Spleen qi deficiency with dampness, and underlying Kidney qi and yang deficiency. Her wiry pulse, premenstrual bloating and moodiness, menstrual cramping, upper back tension and elevated perceived stress demonstrate Liver qi stagnation. Her diagnosis of Spleen qi deficiency with dampness is supported by her fatigue, pale and puffy tongue with wet coat, elevated cholesterol, diarrhea, gas, and bloating. When Spleen qi is deficient, the Spleen is unable to fulfill its function of holding blood, leading to heavy menstrual bleeding and mid-cycle bleeding. This patient presented with a constitutional deficiency of the Kidneys, evidenced by the congenital malformation of the uterus, heavy menstrual flow, lifelong fatigue, tendency to cold, and weak, deep pulses in the chi position.[6]
The primary treatment principle for this case was to course Liver qi, tonify Spleen qi, transform dampness, and stop bleeding. Additionally, as a fertility patient, the treatment principle was adjusted to nourish Kidney yin during the follicular phase and tonify Kidney yang during the luteal phase.
During her initial consultation and treatment, weekly acupuncture sessions, Chinese herbs, and moxibustion were recommended for a minimum of three months.
ACUPUNCTURE TREATMENT
Acupuncture was performed with DBC brand (Korea, .16×15-30mm) needles. Needle length selection was dependent on point location, with 15mm needles typically used on points on the ears and face, and 30mm needles used on most body points. Needles were retained for 25 minutes.
Point selections were based on the phases of the menstrual cycle, with point functions sourced from A Manual of Acupuncture.[7] Pulse was taken before and after needling to assess response to the needling protocol. Occasional variations from the protocol outlined below occurred in order to address specific symptoms presented at that visit or to balance the pulse.
Unless specifically noted with R for right or L for left, points were needled bilaterally. Needling technique used is noted with the following key:
- = represents even technique
- – represents reducing technique
- + represents reinforcing technique
When noted, moxibustion was used at specific acupuncture points after acupuncture needles were retained and removed. Yamasho brand Choseikyu Ibuki stick-on moxa (regular heat, 0.2″ diameter x 0.4″L rolled cylinders) was used for moxibustion therapy. Cylinders were allowed to burn down to ¾ length before being removed and replaced.
Menses Phase (CD1-4)
During the menses phase, regulate qi and blood, regulate menses, calm spirit using:
- Liv 3 – : spread Liver qi, regulate menstruation, regulate lower jiao
- LI 4 – : point combination “Four Gates” with Liv 3 to regulate qi
- St 36 + : supports correct qi and fosters original qi, tonifies qi
- Sp 6 = : regulates menstruation, invigorates blood, harmonizes the lower jiao
- GV 20 + : raises yang, calms spirit
- Yin Tang = : calms spirit
Follicular Phase (CD5-11)
During the follicular phase, tonify Spleen qi, transform dampness, soothe Liver, and nourish blood and yin using:
- Sp 3 + : tonifies Spleen and resolves dampness
- Moxibustion, 3 stick on moxa cylinders
- St 36 + : supports correct qi, fosters original qi, tonifies qi and nourishes blood and yin
- Moxibustion, 3 stick on moxa cylinders
- Lu 7 (L) =, K 6 (R) = : open Ren Mai to support yin
- CV 4 + : fortifies original qi and benefits essence, tonifies Kidneys, fortifies Spleen, benefits uterus and assists conception
- Liv 3 = : spread Liver qi, nourishes Liver blood and yin
- Sp 9 – : resolve dampness
- GV 20 + : raises yang, calms spirit
- Yin Tang = : calms spirit
Ovulation (CD12-14)
During the ovulation window, support smooth transition of yin to yang by regulating qi and stop irregular uterine bleeding using:
- Liv 3 – : spread Liver qi, regulate menstruation, regulate lower jiao
- LI 4 – : point combination “Four Gates” with Liv 3 to regulate qi
- Sp 6 = : regulates menstruation, invigorates blood, harmonizes the lower jiao
- Zi Gong Xue = : regulates qi and regulates menstruation
- CV 4 = : fortifies original qi and benefits essence, tonifies Kidneys, fortifies Spleen, benefits uterus and assists conception
- K 3 + : nourishes Kidney yin, tonifies Kidney yang
- GV 20 + : raises yang, calms spirit
- Yin Tang = : calms spirit
- Sp 1 : stops bleeding, regulates Spleen
- Moxibustion only, 3 stick on moxa cylinders
Luteal Phase (CD15-Onset of Menses)
During the luteal phase, tonify and raise qi, tonify yang, regulate qi, and calm spirit using:
- K 3 + : tonifies Kidney yang
- K 7 + : benefits the Kidneys
- St 36 + : supports correct qi, fosters original qi, tonifies qi and nourishes blood and yin
- Moxibustion, 3 stick on moxa cylinders
- Liv 3 = : smooth Liver qi
- P 6 = : regulates qi, calms the spirit
- GV 20 + : raises yang, calms spirit
- Yin Tang = : calms spirit
- Ear Shen Men = : calm spirit
HERBAL TREATMENT
All formulas were custom blended Five Flavors Herbs brand alcohol based tinctures, using premixed classical formulas with dui yao herb additions. All herbal formula functions were sourced from Formulas and Strategies unless otherwise noted.[8] The daily dosage was 3 dropperfuls taken with a glass of warm water twice per day.
Menses Phase (CD1-4)
No herbal treatment was given during the menstrual phase.
Follicular/Ovulation Phase (CD5-14)
During the first 3 months of treatment, Xiao Yao San combined with Liu Jun Zi Tang was administered during the follicular phase to regulate Liver qi, tonify Spleen, and dry dampness.
The custom herbal tincture consisted of:
- 45% Xiao Yao San (proprietary blend of dang gui, chai hu, bai shao, fu ling, bai zhu, sheng jiang, zhi gan cao, bo he)
- 45% Si Jun Zi Tang (proprietary blend of ren shen, bai zhu, fu ling, zhi gan cao)
- 10% Chen pi and zhi ban xia (proprietary blend)
After 3 months of treatment, the symptoms of Spleen qi deficiency and dampness had significantly improved. The patient observed at her yearly physical that her cholesterol had improved from previous years without any dietary or lifestyle changes on her part. At this point, the formula was adjusted to a combination of Xiao Yao San with Liu Wei Di Huang Wan to regulate Liver qi, tonify Spleen, and nourish yin and blood.
The custom herbal tincture consisted of:
- 50% Xiao Yao San (proprietary blend of dang gui, chai hu, bai shao, fu ling, bai zhu, sheng jiang, zhi gan cao, bo he)
- 50% Liu Wei Di Huang Wan (proprietary blend of shu di huang, shan zhu yu, shan yao, fu ling, mu dan pi, ze xie)
Luteal Phase (CD15-Onset of Menses)
A combination of Xiao Yao San and Jin Gui Shen Qi Wan was administered during the luteal phase to regulate qi, support qi, and tonify Kidney yang.
The custom herbal tincture consisted of:
- 50% Xiao Yao San (proprietary blend of dang gui, chai hu, bai shao, fu ling, bai zhu, sheng jiang, zhi gan cao, bo he)
- 50% Jin Gui Shen Qi Wan (proprietary blend of shu di huang, shan zhu yu, shan yao, fu ling, mu dan pi, ze xie, gui zhi, zhi fu zhi)
RESULTS
The patient noticed changes to her menstrual cycle from the first acupuncture treatment. She got her period immediately after her first treatment. Her cycle was very heavy on the first day, but then tapered to moderate flow by the second day, ending completely after 5 days. Prior to this, she could experience bleeding with intermittent flooding for up to 7 days, followed by a short interval without bleeding before she started midcycle bleeding. Through the course of treatment, the patient continued to experience moderate bleeding during her period with reduced clotting and rare episodes of menstrual flooding.
There was marked reduction in midcycle bleeding during her first acupuncture cycle: the patient had only spotting. Midcycle bleeding resolved completely during her first two cycles while being treated with TCM, during subsequent cycles she experienced either no spotting or single episodes of spotting around ovulation. The final major menstrual cycle change that occurred was stabilization in the length of her cycle to approximately 28 days each cycle.
The patient conceived in early 2020. She experienced some mild first trimester symptoms, including nausea, fatigue, and mild cramping. She continued weekly acupuncture sessions until treatment had to be discontinued due to office closure during the initial wave of the COVID-19 pandemic. She returned to acupuncture treatment during her 3rd trimester to address late pregnancy concerns such as back and hip pain. The patient carried to term and delivered a healthy 6lb 3oz boy by C-section at 37 weeks.
DISCUSSION
This case presents a multifaceted approach to treating complex fertility cases that is typical of TCM. In this particular case, the characteristic presentation of Spleen qi deficiency with dampness and stagnation in PCOS was complicated by a constitutional deficiency of the Kidneys. A combination of classical formulas tailored to this patient’s presentation helped to simultaneously improve the excess and deficient aspects.
Many patients who seek TCM for fertility do so while simultaneously utilizing biomedical fertility treatments, making it hard to determine whether or not TCM helped to achieve clinical pregnancy. Because this patient was not ready to try any biomedical fertility treatments, this case helps to demonstrate the ability of TCM to address infertility as a stand-alone treatment. However, it is impossible to determine definitively if this particular patient became pregnant due to TCM treatment, as she may have eventually conceived without TCM treatment.
CONCLUSION
Menstrual irregularity, and difficulty conceiving are very common in patients with PCOS. Most women who are trying to conceive with PCOS are offered fertility drugs or IVF.[9] Acupuncture has been shown to be beneficial for women with PCOS who struggle with infertility.[10]
Little peer-reviewed evidence currently exists exploring the effects of acupuncture in combination with other TCM methods such as herbs and moxibustion for fertility, and in particular among fertility patients with PCOS. This case suggests that combined TCM treatment methods should be considered for PCOS patients who are unable or unwilling to use ART methods such as IVF. More research is needed to further elucidate the safety and efficacy of TCM as a treatment for infertility in PCOS patients.
REFERENCES
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