Treating Male Infertility using Integrative Medicine

Original title: Acupuncture and TCM in Collaboration with Western Medicine in the Treatment of Male Infertility

Abstract

Traditional Chinese Medicine and Western Medicine have both demonstrated efficacy in the treatment of male factor infertility, which has become a current global health crisis. The purpose of this article is to examine the clinical benefits each modality has to offer; to suggest how TCM and Western Medicine models can be used collaboratively to improve and enhance clinical outcomes; and to reference studies that demonstrate TCM should be considered as a viable modality in the treatment male factor infertility, as well as to suggest some treatment advantages that TCM has to offer the male infertility patient.

Research Methodology

Material for this article was obtained through Pub Med, NIH and Google searches, utilizing a maximum 10-year time frame backwards from 2021. These search terms were used: TCM, Acupuncture and Male Infertility; Idiopathic Male Infertility (IMI); IVI/IUI costs; assisted reproductive technologies. Any articles involving animal studies were excluded. Research articles and studies from both international and US sources were read and references were included if relevant to the subject matter and intent of this article. Additional references and personal knowledge and comments included here were obtained during a 16-month period of clinical rounds, shadowing MD’s in their practices, at the Keck Medicine of USC Urology Clinic in Los Angeles, and through anecdotal experiences in my own acupuncture clinical practice.

Introduction

Infertility overall is significantly on the rise worldwide. A number of epidemiological data sources, including from the World Health Organization, suggest that 15% of all couples trying for pregnancy are unable to conceive a child within the WHO infertility defined period of time for proper evaluation (infertility is defined by the WHO as “a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse.”(1) The diagnostic designation indicated by the WHO definition of male infertility (N46) and female infertility (N97) also correlates with the current International Classification of Diseases (current ICD 10 codes, with respective codes depending on the specific pattern differential diagnosis).

A 2019 WHO article, in their Human Reproduction Programme Journal(2) stated in its heading: “Infertility is a global public health issue.”

In presenting an extreme position, some future-looking literature and progressive epidemiological studies have even proposed that, given a known, progressive increase in worldwide infertility, this global condition could represent a pending threat to humankind’s future ability to maintain our species.

On a more individual, personal level, for those desiring to have a child, the lack of success in conceiving can be a devastating emotional experience. It can lead to manifestations of stress, disharmony, feelings of guilt, shame and blame amongst couples and families.

MALE FACTOR INFERTILITY: In a review of numerous literature sources, depending on the study and its conclusions, male factor infertility may be recognized as having a 40-50% causal factor with a couple having an infertility diagnosis. In one research analysis done by Agarwal et al. (2015)(3), the authors stated: “Infertility affects an estimated 15% of couples globally, amounting to 48.5 million couples. Males are found to be solely responsible for 20-30% of infertility cases and contribute to 50% of cases overall. However, this number does not accurately represent all regions of the world, and on a global level, there is still a lack of fully coordinated statistics and disagreements on rates of male infertility.”

Map: Reproductive Biology and Endocrinology study: Male infertility factor map showing worldwide distribution by region. Agarwal et al. Reproductive Biology and Endocrinology (2015) 13:37, DOI 10.1186/s12958-015-0032-1

In regard to idiopathic male infertility, (IMI), that factor for which the cause is unknown or undetermined after a thorough assessment, this condition accounts for 30% to 50% of all cases involving infertility solely on the male side.(3),(28) This is a multifactorial condition which contributes to emotional stressors, blame, shame, and disappointment among those partners desiring to have their own biological children. Attempting to ameliorate these complex conditions can subsequently result in extensive treatment periods and significant healthcare costs for the various treatments, often with unreliable, inconclusive, or no benefit. Additionally, healthcare insurance or reimbursement for fertility treatments is not often covered, or is very limited in scope.

Nevertheless, infertility science and reproductive technology have made great strides in dealing with male infertility,(28) and these have come a long way since looking to a female partner solely for etiologies of infertility. Western Medicine offers many important diagnostic capabilities, as well as treatment modalities, that have demonstrated effectiveness in improving male factor infertility.(28) Traditional Chinese Medicine (TCM) has been used in China with much anecdotal success for over 2000 years in the treatment of male infertility, and benefits from numerous more contemporary TCM based studies have also been well demonstrated. However, what I found is that many of these studies commonly acknowledge weaknesses that exist in those studies, whether through methods utilized, or more so by virtue of conclusions reached using smaller study subject size groups. The suggestion is that additional quality research and quantity of TCM based clinical studies are needed to help demonstrate added positive treatment outcomes, and to provide evidence-based efficacy correlations.

Traditional Chinese Medicine and its treatment methods, including acupuncture and the use of specific herbal formulations, will be presented in this article to help demonstrate how these methods could be considered as a viable option along with any treatment approach. I will suggest how TCM, either used alone when indicated, or working collaboratively with Western Medicine, utilizing its modalities and diagnostic capabilities, can together creatively help to ameliorate the complex conditions often associated with male factor infertility.

DISCUSSION

MALE INFERTILITY FACTORS AND THE WESTERN MODEL TREATMENT APPROACH

Western Allopathic Medicine has established treatments for male infertility conditions, and has determined various differential diagnoses used to establish specific treatment approaches for these conditions. Commonly, these diagnoses are as follows: Azoospermia (lack of any viable sperm); Oligospermia (below normal sperm count); Teratospermia (problems in the morphology of existing sperm); Asthenozoospermia (poor motility of sperm); Oligoasthenoteratozoospermia (a mixed pattern in combination, indicating low sperm count, poor motility and sperm morphology issues). Other identifiable conditions affecting male fertility can include: endocrine imbalances or dysfunction (a hypothalamic-pituitary-gonadal/testes axis dysfunction – the HPG/T axis); endogenous testosterone levels; chromosome/genetic abnormalities; sperm cell autoimmunity; male anatomical/structural conditions affecting either production or transmission of sperm; e.g., varicocele (a varicose enlargement of the veins of the spermatic cord producing a soft compressible tumor mass or twisting in the scrotum), testicular traumas/pathologies, duct obstruction, retrograde ejaculation); Reactive Oxidative Stress (ROS); sperm DNA fragmentation; misuse of exogenous testosterone supplementation; and excess inflammatory factors, both systemic and external. Hypertension, environmental, stress factors, and the age of a man also can play key roles in fertility.

I believe Western Medicine is particularly needed and effective for anatomical or structural issues that affect sperm production or transmission. For example, varicocele, vasectomy reversals, retrograde ejaculation, and sperm harvesting from the testes for oligospermia are all surgical intervention procedures utilized. Even in some cases of azoospermia, because different regions of the testes may produce small amounts of sperm not showing up in semen, some physician infertility specialists are even able to harvest viable sperm (ICSI) from these areas for use in IUI or IVF procedures, known as Assisted Reproductive Technology (ART) procedures.

Through my clinical observation rounds at Keck Medicine of USC, I was able to follow patient treatments with effective benefits for male infertility, including vasectomy reversals and the use of pharmaceuticals, and through sperm capture which is delivered via Assisted Reproductive Technology such as IVF/ICSI. When it comes to issues of anatomy affecting fertility, such as varicoceles, tumors, blocked vesicles, reversing vasectomies, or other conditions possibly requiring surgical intervention, a Western Medical approach seems the most viable option.

From the National Institute of Health, Eunice Kennedy Shriver Child Health and Human Development website, comes the following statements of advice provided to their readers, regarding male infertility:(4)

“Medication can treat some issues that affect male fertility, including hormone imbalances and erectile dysfunction. Surgery can be effective for repairing blockages in the tubes that transport sperm from the testicles to the penis.”(4) “Surgery also can be used for repair of varicocele, or varicose veins, in the testicles. Current research suggests that surgical repair of varicocele can improve the health of sperm, but it has not affected the chances for conception.”(5) “If surgery does not restore fertility, ART can be effective.”(4)

The professional group, The Society for the Study of Male Reproduction, offers the following recommendations to patients for treatment options from their website:(6)

“Some conditions contributing to male infertility can be treated with medication, usually known as ‘medical therapy.’ For example, retrograde ejaculation (6) may often be treated with alpha-receptor agonists and immunologic infertility (6) may be treated with anti-inflammatory or steroid medications. In addition, pituitary hormone deficiency may be corrected with drugs such as clomiphene or gonadotropins.”

Specifically, the SSMR group goes on to conclude:

“If these techniques fail, fertility specialists have a variety of other high-tech assisted reproductive technologies (ART) that support conception without intercourse.”

And the renowned Cleveland Clinic (7), offers these male infertility treatment options: “medical therapy; surgical treatment; vasectomy reversal and microsurgical reconstructive surgery; in-vitro fertilization (IVF); intracytoplasmic sperm injection (ICSI); sperm extraction for in-vitro fertilization.”

When it comes to non-surgical interventions, or other than the use of ART in male fertility conditions, other options seem less utilized within the Western Medical models, and also have other issues with their usage.

Interestingly, many men chose to self-administer exogenous testosterone supplements if infertility is suspected, and this practice was often witnessed during my doctoral clinic rounds. And in a one survey,(8) “some (up to 25%) of urologists have used T replacement therapies in an attempt to improve fertility. Unfortunately, this does not work, as the exogenous T ultimately inhibits pituitary LH/FSH production. In fact, exogenous T is used to promote infertility as a form of male birth control.”

According to an article published in the March 2015 Journal of the American Society for Reproductive Medicine (ASRM),(9)

“Gonadotropins are the only class of medications approved by the FDA for the medical management of male factor infertility. Gonadotropins include GnRH, LH, and FSH and are used to treat hypogonadism and hypospermatogenesis.”(9,10)

One of these is the prescription drug, clomiphene citrate (Clomid), a commonly utilized pharmaceutical treatment for male infertility, functioning at the male hormonal level. During my personal observation in clinical rounds at the Keck Medicine/USC Urology clinic, in cases of idiopathic azoospermia, oligospermia or asthenozoospermia, the use of Clomid was a frequently prescribed option, when other physical, anatomical or other known factors were ruled out. There are some successful clinical benefits of taking Clomid to enhance endogenous testosterone and influencing the H-P-G axis.

Yet, according to the same article,(9,10) “There have been mixed results from clinical studies testing the effectiveness of taking clomiphene citrate for male infertility. The drug may improve sperm motility for some males. However, using clomiphene citrate may reduce total sperm count in some males. This reduction may relate to dosage of the medication… In males, clomiphene citrate increases levels of luteinizing hormone (LH) and follicle-stimulating hormone (FSH). Increasing the level of these hormones in the body can lead to an increase in testosterone and the creation of more sperm. However, hormone interactions are complex, and there is not currently enough research to know whether boosting LH and FSH has a direct impact on male fertility. Taking clomiphene citrate may work for some males and not others.”(9,10)

Because the FDA has not approved clomiphene citrate for treating infertility in males, there is also no agreement on the best dosage. For this reason, doctors need to rely on their own judgment when prescribing this drug. As a result of this lack of approval, health insurances typically will not pay for this prescription treatment.

“Treating the 50% of infertile men with idiopathic infertility is a vexing problem with limited options. Treatment options include enhanced medical therapies (EMTs). Unfortunately, the use of these off-label pharmaceuticals has both varied and unreliable results.”(9,10)

According to a 2012 publication of the European Association of Urology Guidelines on Male Infertility, evidence-based data are limited in the empirical use of drugs for idiopathic MI, and some drugs have obvious side effects. Potential side effects of Clomiphene Citrate indicated in the article include: headaches, nausea, tenderness of the pectoral muscle, irritability, decreased libido, acne, testis pain, acceleration of prostate cancer growth (if cancer is already present) and changes in vision that are caused by a swelling of the pituitary gland.(11)

Regarding the use of ART, cost is also a consideration in this common Western Medicine practice. One option utilized in essentially bypassing issues of sperm quantity, motility, or morphology (common male infertility etiologies) is to harvest sperm through a medical procedure directly from the testes, in which sperm are extracted and then used in IVF or ICSI fertilization with the female produced ovum. Yet, IVF and ICSI procedures are costly and can be traumatic.

From an article by Rachel Gurevich, RN, “How Much Does IVF Really Cost, in Verywell Family: “The average cost for one in vitro fertilization (IVF) cycle is $12,000. Basic IVF can be as much as $15,000 or may be as low as $10,000. It’s rarely lower than that. These numbers do not include the cost of medications, which may be as low as $1,500 or as high as $3,000 per cycle. According to at least one study, women who conceived with IVF treatment went through an average of 2.7 cycles. They found that the odds for success—for women of all ages—after three IVF cycles were between 34 and 42 percent. Practically speaking, to improve your odds, you should try for at least three IVF cycles.”(12)

From research presented on the site, fertilityiq.com:(27) “On average, IVF costs well over $20,000 when one includes the cost of treatment and medication”, “it can vary depending upon region and whether a patient opts for add-ons like ICSI or PGT-A.” “Despite IVF’s relative effectiveness, the average fertility patient undergoes over two cycles and so the cumulative IVF costs for most fertility patients reach into the $40,000 – $60,000 range.”

Additionally, evidence suggests “the use of IVF and/or ICSI (intracytoplasmic sperm injection) techniques may increase the risk of birth defects and childhood cancers in the offspring.”(13)

So, establishing efficacy of acupuncture and herbal medicine supplements for IMI, such modalities may be found to be more cost effective than other alternatives. I suggest that additional studies are needed to compare the potential costs of a successful TCM treatment vs. the medical costs for IVF, IUI, or ICSI. Refer to Table E for a study comparing costs for typical Western Medicine approaches for these treatments.

Hypertension has a co-morbidity factor with infertility: “Existing data suggest an association between hypertension and impaired semen quality.” Males with hypertension

have a lower semen volume, sperm motility, total sperm count, and motile sperm count, based upon the WHO 5th edition criteria for sub-fertile semen parameters. And treatment with

beta-blockers and other antihypertensive medication was associated with impairments in semen parameters.”(14). Regarding this co-morbidity factor, TCM modalities might be utilized for treatment as an alternative to, or in conjunction with, other Western Medicine modalities.

THE TCM APPROACH TO MALE INFERTILITY

Regardless of any of the viable options available from Western Medicine in treating male infertility, some patients may simply want to make use of other alternatives, either initially, before seeking Western based treatment, or alongside. This is where TCM, acupuncture and Chinese herbal medicine formulas have much to offer. A number of my fertility clients have chosen to utilize some aspects of both modalities.

Traditional East Asian Medicine, as taught in AOM College acupuncture degree programs throughout the country, referencing various standardized texts,(29) attributes male infertility to one or more of the following differential diagnoses, aka, the specific pattern identification, which is typically crucial to identify in Acupuncture/TCM before determination of a treatment. Common patterns attributed to a male infertility diagnosis include: kidney yang deficiency; kidney yin deficiency; kidney jing deficiency; kidney fire uprising; lower jiao damp heat; chong and ren meridian system disharmony; meridian stasis involving one or more of the liver, kidney or spleen channels; blood stasis, blood deficiency, channel trauma, liver qi constraint; and varying degrees and etiologies of epidemic/environmental and systemic toxicity affecting sperm production. 

One Chinese based Meta-Analysis study(15) from July 2015 PubMed article on the topic of male infertility presented the following evaluations:

“A total of 12 studies involving 2,177 patients were included, the quality of which was evaluated as mediocre. With regard to the cure rate, acupuncture was comparable to traditional Chinese medicine but better than Western medicine while acupuncture + TCM was better than either TCM or Western medicine used alone, and acupuncture + Western medicine was better than Western medicine alone.”

The overall conclusions reached from this meta-analysis study were: “For the treatment of male infertility, acupuncture is reported to be equally effective as TCM and more effective than Western medicine, and its effectiveness is enhanced when applied in combination with either TCM or Western medicine. Acupuncture is distinctively efficacious in improving sperm quality.”(15)

In an open access article entitled “The Effectiveness and Safety of Acupuncture for Poor Semen Quality in Infertile Males: a systematic review and meta-analysis” published in 2014 from the Asian Journal of Andrology,(16) and the following conclusions from their meta-analysis were drawn:

“Four RCTs met the eligibility criteria. Acupuncture increased the percentage of sperm with rapid progression and sperm concentration. No participants experienced adverse events. The current evidence showing that acupuncture might improve poor semen quality is insufficient because of the small number of studies, inadequacy of procedures and/or insufficient information for semen analysis, high levels of heterogeneity, high risk of bias, and poor quality of reporting. Further large, well-designed RCTs are required.”(16)

A summary of the results of the randomized controlled trials of acupuncture for male infertility in this study are shown in Table A.  A summary of the acupuncture points and techniques used in the randomized control trials from the 2014 Asian Journal of Andrology article for male infertility are shown in Table B.

Another study from a May 2019 PubMed article published in the World Journal of Men’s Health entitled, “Traditional Chinese Medicine as a Remedy for Male Infertility: A Review” references these therapeutic mechanisms of Traditional Chinese Medicine and show these proven functions and benefits:(17)

1. Regulation of the reproductive endocrine system; Enhancement of follicle-stimulating hormone levels, regulation of luteinizing hormone levels; reducing follicle-stimulating hormone levels, regulating luteinizing hormone levels; raising testosterone levels; regulating follicle-stimulating hormone and luteinizing hormone levels bi-directionally
2. Boosting the function of Sertoli cells and Leydig cells
3. Preventing oxidative stress
4. Modulating the proliferation and apoptosis of germ cells
5. Supplementing trace elements
6. Ameliorating the microcirculation of the testis
7. Improving semen quality and the pregnancy rate: improving seminal plasma and sperm quality
8. Others: Alleviating inflammation; decreasing the level of anti-sperm antibody; modifying epigenetic markers

“It has been demonstrated that acupuncture can regulate the hypothalamic-pituitary-testicular axis” and “boost the function of Sertoli cells and Leydig cells.” “TCM can also alleviate inflammation, prevent oxidative stress, reduce the DNA fragmentation index, and modulate the proliferation and apoptosis of germ cells. Furthermore, TCM can supply trace elements and vitamins, ameliorate the microcirculation of the testis, decrease the levels of serum anti-sperm antibodies, and modify epigenetic markers.”(17)

A summary of the World Journal of Men’s Health article on the potential therapeutic mechanisms of TCM can be found in Table C.

USE of TCM HERBAL FORMULAS WITH DIAGNOSTIC PATTERN DIFFERENTIATION in MALE INFERTILITY TREATMENT

The TCM model views pattern identification as a crucial determinant in selecting a treatment, and that includes utilizing classic Chinese Medicine herbal formulas. One diagnosis of azoospermia might elicit different herbal supplementation, depending on the dynamics and patterning of the condition; it should therefore be incumbent on a clinical trial or case study to evaluate the particular pattern differentiation when applying desired treatment protocols. For example, from the World Journal of Men’s Health, Traditional Chinese Medicine as a Remedy for Male Infertility: A Review (17)

“For reducing FSH levels and regulating LH levels, Schizandra chinensis polysaccharide (jingui shenqi pill, liuwei dihuang decoction)(18) was shown clinically to decrease FSH levels and increase LH levels; bushen shengjing pill(19) also increased LH levels in kidney-yang deficiency infertile men, and decreased FSH levels in kidney yin deficiency and kidney yin and yang deficient men.”

Another supplement, Cistanche tubulosa (ru cong rong),(20) a phenylethanoid glycoside, was effective in raising testosterone levels, enhancing biosynthesis by increasing the expression of key steroidogenic enzymes (StAR, CYP11A1, 3β-HSD, 17β-HSD, and CYP17A1).

For azoospermia infertility associated with testicular microcirculation issues, bu shen huo xue formula(21) upregulated the protein expression of VEGFR2 and Src via the VEGF/VEGFR2 pathway, ensuring adequate nutrient supply for the testis.

And even for poor sperm counts associated with autoimmune sperm cell antibodies, zhi bai di huang wan decoction “remarkably reduced serum level of AsAb”, eliminated testicular immunological complex and regulated the ratio of CD4/CD8 T cells.(17)

For a complete summary of results from this study, refer to Table D.

From a Journal of Traditional Chinese Medicine study article:(22)

“Human studies do exist for two popular decoctions: wuzi yanzong wan (Pills for Reproduction) and sheng jing zhong zi tang (Decoction for Generating Sperm). A 3-month course of wuzi yanzong wan in 35 infertile men with either asthenospermia or oligospermia and a 3-month course of sheng jing zhong zi tang in a separate cohort demonstrated improved sperm concentration and motility compared to pretreatment sperm parameters.

In concluding remarks, this article stated: “The clinical data on Chinese herbal medications for male infertility are intriguing. The non-standardization of herbal decoctions, however, makes studies difficult to perform. Random clinical trials and standardization of the herbal decoctions are needed to assess the clinical relevance of this treatment.”(16)

TCM TREATMENT OF MALE AUTO IMMUNE RELATED INFERTILITY

A different formulation of sheng jing zhong zi tang was assessed for an effect on antisperm antibodies. Ninety men with isolated male infertility related to either a positive sperm immobilization test (SIT) and/or gelatin agglutination test (GIT) were randomized to 60 days of either sheng jing zhong zi tang (n = 60) or control of prednisone 5 mg and clomiphene 50 mg (n = 30). Treatment with 2 months of sheng jing zhong zi tang decreased IgA, IgG, and IgM (P < 0.01). Treatment with 4 months of prednisone and clomiphene also decreased IgA, IgG, and IgM (P < 0.01), but the improvement was less when compared to 4 months of sheng jing zhong zi tang.

In another Austrian study,(23) the authors report excellent results even in the complexities associated with male auto-immune-related infertility.

“Two hundred cases of male infertility were randomly divided into two equal groups, one of which received prednisone (control) and the other Chinese herbs (treatment). In both groups, the duration of the disease was from two to six years and the average age was 28.75 years. The men had various combinations of abnormal sperm density and motility, seminal and serum antisperm antibodies, chronic prostatitis, epididymitis and seminal mycoplasma. The Chinese herbal formula given to the treatment group was yi kang tang. It consists of chai hu (Bupleuri Radix) 9g, sheng di huang (Rehmanniae Radix) 10g, chuan xiong (Chuan Xiong Rhizoma) 9g, bai hua she she cao (Hedyotis Diffusae Herba) 12g, ban zhi lian (Scutellariae Barbatae Herba) 10g, bai dou kou (Amomi Rotundus Fructus) 9g, yin yang huo (Epimedii Herba) 12g, sheng huang qi (Astragali Radix) 20g, mu dan pi (Moutan Cortex) 9g, zhi mu (Anemarrhenae Rhizoma) 9g and huang bai (Phellondri Cortex) 9g.

Results showed that sperm density and motility increased significantly in the treatment group compared to the control, and that anti-sperm antibodies and sperm agglutination decreased significantly. These results were further confirmed by the pregnancy rates in the treatment group which were double those of the control. In addition, 82% of patients in the treatment group maintained the gains they had made when assessed three months after the end of the trial, compared to approximately half of that figure in the control. The authors conclude that not only were the Chinese herbs more effective than Western Medicine, but they were also free of the side-effects of prednisone in long-term use and its rebound effect.”(23)

A KEY RELATIONSHIP BETWEEN ACUPUNCTURE MERIDIAN MECHANISMS, ENDOCRINE SYSTEM FUNCTION, AND MALE INFERTILITY

From Evidence Based Complementary and Alternative Medicine, 2019:(24)

“Depending on the pituitary, hypothalamic-pituitary-adrenal axis, hypothalamic-pituitary-thyroid axis, and hypothalamic-pituitary-gonadal axis, the relationship is mainly manifested in the release of endocrine hormones after acupuncture. The nervous system plays a leading role in this process, as all effects are generated by the neural arc.”

“Acupuncture can cause specific responses in the local microenvironment of acupoints, such as the activation of cell function, the release of chemical substances, and the excitation of the afferent nerve. The interaction among them may trigger and successively amplify acupuncture signals to produce a whole regulating effect.”

The following conclusions were drawn in a Chinese study, from a Pub Med, January 2018 article titled Acupuncture Treatment of Oligoasthenozoospermia:(25)  

“Studies show that acupuncture can significantly elevate the level of serum testosterone (T), reduce the concentrations of follicle-stimulating hormone (FSH), luteinizing hormone (LH) and estradiol (E2), initiate spermatogenesis, enhance testicular blood flow, maintain a relative low temperature in the testis, increase the concentration, motility and antioxidative injury capability of spermatozoa by raising the levels of seminal α-glucosidase, fructose and superoxide dismutase, and eventually improve semen quality and the rate of conception in the treatment of oligoasthenozoospermia. Currently, the quality of the clinical studies of acupuncture treatment of oligoasthenozoospermia is relatively poor, the existing evidence remains at a low level, its clinical application is limited, and its therapeutic effect has to be further verified.”

PROPOSED ADVANTAGES OF TCM TREATMENT MECHANISMS

From the World Journal of Men’s Health, May 2019(17):

“We propose the following potential mechanisms of TCM treatments of MI: regulation of the H-P-T axis, boosts to the function of SCs and LCs, alleviation of inflammation, prevention of OS, and reduction of the DFI. TCM also acts to modulate the proliferation and apoptosis of germ cells, supply trace elements and vitamins, ameliorate the microcirculation of the testis, decrease AsAb levels, and modify epigenetic markers. TCM has effects on multiple targets, systems, and pathways to improve sperm parameters and the pregnancy rate. The therapy of TCM focuses on overall balance by improving the condition of the body and regulating the testis, instead of complementing a certain hormone directly. Moreover, natural products have few side effects. This may be the underlying mechanism for the bi-directional effects of TCM on disordered hormone levels.”

TCM AND WESTERN MEDICINE, TOGETHER

This statement from a research article(26) by two Western M.D. Urologists, practicing at the UCLA Men’s Clinic, and specializing in male fertility, expresses an understanding of the value of acupuncture treatments: “Acupuncture is a key component in TCM fertility therapy. Acupuncture is often an adjunctive therapy, used with or without electrical stimulation, and in combination with herbal medicines for male infertility.” “A study of 57 men with severe oligoasthenospermia underwent either true or placebo acupuncture. Those who underwent true acupuncture experienced improvement in total motile sperm counts (33.8% vs 24.4% motility A-C, P = 0.035) but lower semen volume (3.7 vs 4.2 ml, P = 0.041).”

“In a physiologic study of 80 healthy men 30–35 years of age, Doppler ultrasound flowmetry was used to assess differences in testicular blood flow before and after abdominal electroacupuncture. Men who received acupuncture at points correlating to genital problems (St 29 or guilai) with electrical stimulation (10 Hz) demonstrated improvements in testicular blood flow (P < 0.005).”

CONCLUSION

I believe there are opportunities available right now for acupuncturists and TCM practitioners to work together with Western based doctors on fertility conditions, be they male or female based. I think it’s important then, for acupuncturists to be able to understand Western fertility terms and treatments, and also be able to “speak TCM” to Western physicians in a way that they can grasp and embrace our language, concepts and treatments. I have found what initially seemed to me a surprising number of Western fertility doctors willing to embrace our medicine, even if, as many have told, me, they don’t need to fully understand its mechanisms in order to believe that it works. And, as more than a few MD’s have said to me “My patients want these other options as well.”

Earlier I mentioned the example in which a physician might use microscopic sperm extraction (microTESE) from an azospermatic male, in order to harvest even a small number of sperm from a promising area in the testicle. If successful, this extraction could then be utilized in an IVF or an ICSI procedure. But how much more successful might such a procedure be, if the patient were also being treated with acupuncture and/or herbal formulas, to enhance the potential to build more sperm cells? Though there is variation, fully developed, viable sperm take about 72-74 days to produce from start to finish (spermatogenesis); what if, in between timing of IUI or IVF treatment cycles, this man was receiving acupuncture or herbs to help increase the quantity or quality of sperm, instead of some of the drawbacks of using Clomid, or receiving nothing?

How might a highly stressed, busy, corporate male, having difficulty conceiving with their partner – even choosing to go the IVF route – benefit from reduced stress and better sleep, so as to balance and enhance their endocrine and hormonal functions, and make more viable sperm?

And, how many acupuncture treatments and herbal supplements would be effective in treating a man who has been unable to conceive for a year, but whose problem lies with a varicocele, or other undiagnosed internal anomaly, that is preventing even viable sperm from getting where it needs to go?

With an abundant volume of clinical research available, actual, real world clinical practices have shown varying degrees of effective treatment in male infertility cases, in both Western and TCM/Eastern/Complementary Medicine modalities. In comparison, direct correlations between the two systems and their respective terminologies, understanding and diagnoses can also be made. Knowledge of both systems, and the ability to view each collaboratively, can be an important skill to have in establishing a correct differential diagnosis and offering effective, successful treatment of male infertility conditions.

Dr. Bruce Gustafson, DAOM, LAc., Dipl. OM (NCCAOM)® maintains a private practice, Acumen LifeCare, specializing in Integrative Andrology Medicine, Men’s Wellness, and both male and female fertility issues. As part of his Doctoral Capstone Project, he participated in a 16-month long clinical rounds mentorship at the Keck Medicine/USC Department of Urology, where he experienced Western Medicine perspectives and treatment modalities available for urology patients and for male infertility clients. He also travelled to China and received advanced clinical training in TCM Integrative Medicine at Shanghai TCM University and Longhua Hospital, with one section focused specifically on fertility. Dr. Bruce is the Associate Academic Dean and a Faculty member at Emperor’s College in Santa Monica, CA. In addition, he serves as an Executive Board member of CSOMA, a California Acupuncture Association, and participates as a member of the American Society of Andrology (ASA), the Society for the Study of Male Reproduction (SSMR), and the Society for Acupuncture Research (SAR). Dr. Gustafson has developed a complete TCM treatment protocol that could potentially be used in additional evidence-based research projects, to guide and help evaluate the efficacy of acupuncture and traditional herbal formulas to treat oligospermia.

Addendum

Table A: https://pubmed.ncbi.nlm.nih.gov/25038176/ (Table 1)

Table B: https://pubmed.ncbi.nlm.nih.gov/25038176/ (Table 2)

Table C: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6479084/ (Figure 1)

Table D: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6479084/ (Table 1)

TABLE E:https://www.fertilityiq.com/ivf-in-vitro-fertilization/costs-of-ivf#cost-components (Comparing Fertility Treatments)

References

1. Maya N. Mascarenhas, Seth R. Flaxman, Ties Boerma, Sheryl Vanderpoel, Gretchen A. Stevens

National, Regional, and Global Trends in Infertility Prevalence Since 1990: A Systematic Analysis of 277 Health Surveys Published: December 18, 2012 https://doi.org/10.1371/journal.pmed.1001356 (accessed 11/2019)

1.  https://www.who.int/reproductivehealth/topics/infertility/perspective/en/
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3. https://www.nichd.nih.gov/health/topics/infertility/conditioninfo/treatments/treatments-men#f1
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5. https://ssmr.org/patients/treatment-for-male-infertility/medical-and-other-treatments.aspx
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17. Constituents: aconti radix preparata, cinnamomi ramulus, rhemanniae radix and preparata, corni fructus, dioscoreae rhizoma, alismatis rhizoma, poria, mouton cortex.
18. Constituents: cuscutae semen, dipsaci radix, morindae officinalis radix, eucommiae cortex, cornu cervi degelatinatium, angelica sinensis radix, rhemanniae radix preparata, lycii fructus, asini corni colla, codonopsis radix, atractylodis macrocephalae rhizoma, jujube fructus, amomi fructus.
19. Constituents: rhemanniae radix, angelica sinensis radix, cuscutae semen, lycii fructus, psoraliae fructus, corni fructus, cistanches herba, myrrh, carthami flos, gentianae macrophyllae radix, eucommiae cortex.
20. Constituents: anemarrhenae radix, phellodendri cortex, rhemanniae radix preparata, corni fructus, dioscoreae radix, poria, mouton cortex, alismatis rhizome.
21. Yang BC, Zhang CX, Yang J. Clinical observations on therapeutic effects of the modified shengjing zhongzi tang (see text) in patients with asthenospermia and oligozoospermia. J Tradit Chin Med. 2011;31(3):192–194. doi:10.1016/s0254-6272(11)60040-x
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