News Letter, Vol. 7 (1), January, 2016 © Copyright
Acupuncture and Infertility
Jun Xu, M.D. Lic. Acup., Hong Su, C.M.D., Lic. Acup.
Rehabilitation Medicine and Acupuncture Center
1171 East Putnam Avenue, Building 1, 2nd Floor
Greenwich, CT 06878
Tel: (203) 637-7720
Amy S., a 36-year-old woman, is an OB-GYN at a Connecticut hospital, who delivers babies every day. When she finished her residency two years ago, she and her husband wanted to have a baby and tried for a pregnancy for a year to no avail. As a doctor, Amy is well aware of the workings of her body. She consulted the best endocrinologist and infertility specialist in the area, who checked her hormone levels, including the thyroid, pituitary gland, adrenal gland, ovaries, etc., only to find nothing was wrong. She was careful about nutrition, was at her ideal weight of 120 pounds and neither drank nor smoked. She also had an ultrasound study which showed no problem in her tubes, uterus or ovaries. Amy’s husband was also examined and shown to have a normal quantity and quality of sperm with no antisperm antibodies; the delivery of his sperm was also normal. He showed no retrograde ejaculation and no blockage in the ejaculatory duct.
Amy came to me for consultation and evaluation. She is an open-minded physician, devoted to her job, and works between 55 and 60 hours a week. Her husband is an emergency physician who works in the same hospital and he, too, works hard. Amy and her husband are often on call, causing much stress. They both keep irregular hours and often do not see much of each other. From her history, I could tell she was very stressed, unhelpful to her pregnancy situation.
Amy told me she had read an article which indicated that acupuncture plus IVF (in vitro fertilization) could help the patient increase the success rate for pregnancy. She tried it once without success.
Based on the above information, Amy has unexplained infertility. Unexplained infertility is, by definition, when a couple has not conceived after 12 months of contraceptive free intercourse.
In order to understand Amy’s condition, let’s discuss some basic physiology of women.
· Basal Body Temperature (BBT) is women’s body temperature at rest (wake up time).
· BBT rises after ovulation due to increased progesterone released from the corpus luteum after ovulation.
· Ovulation can be detected on a fertility chart for the day BEFORE the temperature rises.
· When ovulation is detected on a fertility chart, the chart shows a biphasic (lower temperatures followed by higher temperatures) pattern.
· BBT stays in the higher range throughout the luteal (post-ovulation) phase until the next cycle begins.
· BBT stays high if there is a pregnancy.
What is this BBT chart about?
· Follicular phase
The follicular phase begins on Day 1 of the menstrual cycle. Estrogen and progesterone levels are at their lowest during menstruation. During this phase the uterine lining, or endometrial lining, both sheds through menstruation and begins a period of regrowth and thickening in preparation for an embryo should conception occur.
The follicular phase lasts about 10 to 14 days, or until ovulation occurs.
Before a woman ovulates, the basal body temperatures range from around 97.0 to 97.5 degrees Fahrenheit (36.1 to 36.3 Celcius). This is due to the presence of estrogen, which keeps temps down. Temperatures will vary from person to person, but should stay below your cover line.
The luteal phase begins when ovulation occurs. During ovulation, the ovaries release a single egg from only one of the two ovaries during each menstrual cycle. Ovulation is a process that begins when the level of luteinizing hormone or LH surges, and ends 16 to 32 hours later with the release of an egg from the ovary.
Once ovulation has occurred, the temps go up from around 97.6 to 98.9 F (36.4 to 36.6 C). The day after ovulation, the temp generally jumps up by at least 0.2 degrees F (0.11 degrees C), and then continues to rise somewhat. This increase in temperature is caused by the progesterone released from the follicle after ovulation.
The actual temperatures are less important than noting a pattern showing two levels of temperatures. If there is no pregnancy, then this temperature will stay elevated for 10 – 16 days, until the corpus luteum regresses. At this time, progesterone levels drop dramatically and you get your period.
If your Basal Body Temperature remains elevated for 18 days or more after ovulation, you should probably test for pregnancy.
· After ovulation, the corpus luteum produces the heat-inducing hormone, progesterone to prepare the lining of the uterus for the implantation of a fertilized ovum. Progesterone causes the resting body temperature to rise after ovulation so that it is possible to identify ovulation for the day BEFORE the temperature rises.
· A fertility chart that shows ovulation detected by BBT will have a BIPHASIC pattern. This means that it will show lower temperatures before ovulation, a rise (thermal shift), and then higher temperatures after ovulation. Ovulation usually occurs on the last day of lower temperatures. Then higher temperatures after ovulation.
· To illustrate, see the image below. The blue dots represent daily temperature readings. Ovulation is identified by the vertical red line. The horizontal red line is a “cover line” to help to visualize the biphasic pattern.
Conception takes time
· A normal, healthy couple only has a 25 percent chance of conceiving each month, even when they have sex right around the time of ovulation. After a year of trying, 75 to 85 percent of couples will have conceived.
· If your Basal Body Temperature remains elevated for 18 days or more after ovulation, you should probably test for pregnancy.
6 Pregnancy Tips
1. Have Intercourse Often: Sperm can survive in a woman’s body for up to 5 days. To increase your odds, you should have sex frequently 3 days before ovulation and continuing for 2 to 3 days after you think you’ve ovulated.
2. Lie Low after Sex: Sperm has to swim upstream to meet your eggs, stay in bed for at least a few minutes after intercourse.
3. Create a Sperm-Friendly Environment: Avoid putting any chemicals into your vagina, such as vaginal sprays, scented tampons, artificial lubricants, and douching. They can alter the normal acidity of the vagina.
4. Know When You Ovulate: Please use the above chart to estimate your ovulation day. You might also use an over-the-counter ovulation predictor kit (OPK) to check for hormonal changes in your urine before ovulation.
5. De-Stress: Try acupuncture, yoga, meditation, or long walks to reduce stress. Research indicates that stress can interfere with getting pregnant.
6. Maintain a Healthy Weight: Studies show that weighing too little — or weighing too much — can disrupt ovulation and may also affect production of key reproductive hormones. A healthy BMI is between 18.5 and 24.9.
Definition of Infertility:
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.(WHO).
There are many causes of infertility, including the following:
For the male:
1. Impaired production and function of sperm, low sperm concentration. Normal sperm concentration is greater than or equal to 20 million sperm per milliliter of semen. A count of 10 million or fewer sperm per milliliter of semen indicates low sperm concentration, and the chances of conception lessen. A count of 40 million sperm or higher per milliliter of semen indicates increased fertility; also, if a sperm changes its shape and mobility or is slow, the sperm may not be able to reach or penetrate the egg.
2. The malfunction of the Hypothalamic-Pituitary-Gonadal Axis: if the axis is not working properly, the male hormone level will be disturbed and the sperm will be both low in count and slow in activity.
3. The testes system, including transportation and maturation.
For the female:
1. Fallopian tube damage or blockage.
3. Ovulation disorders.
4. Hormonal causes, such as hypothyroidism,
4. Early menopause.
5. Polycystic ovary syndrome.
6. Fibroid in the uterine.
Even though there are many women who cannot conceive because of the above reasons, there are also 15-20 % of couples who cannot conceive due to unexplained reasons, and Amy falls into this category. Therefore, many couples have to use the following technology for help.
Assistant Reproductive Technology:
1. Intrauterine Insemination (IUI)
Intrauterine insemination is the placement of a man’s sperm into a woman’s uterus using a long, narrow tube, which usually help the sperm to go upstream to meet eggs. The successful rate sometimes can be 20%.
2. In Vitro Fertilization (IVF)
Eggs and sperm are taken from the couple and are incubated together in a dish in a laboratory to produce an embryo. The embryo then will be placed into the woman’s uterus, where it may implant and result in a successful pregnancy.
A. IVF stimulation protocols in the US generally involve the use of 3 types of drugs:
1), Medications to suppress the luteinizing hormone (LH) surge and ovulation until the developing eggs are ready.
There are 2 classes of drug used for this:
GnRH-agonist (gonadotropin releasing hormone agonist) such as Lupron,
GnRH-antagonist such as Ganirelix or Cetrotide
Lupron essentially “shuts down” the body’s reproductive hormone system.
While shut down, IVF patients use a follicle stimulating hormone (FSH) drug like Gonal-F or Follistim, to cause the recruitment and development of follicles. Dosages of FSH are adjusted based upon each patient’s response and it is continued until the follicles are mature.
2), FSH product (follicle stimulating hormone) to stimulate development of multiple eggs
Gonal-F, Follistim, Bravelle, Menopur
3), HCG (human chorionic gonadotropin) to cause final maturation of the eggs
The ovaries are stimulated with the injectable FSH medications for about 7-12 days until multiple mature size follicles have developed.
Ovulation cannot occur naturally while on Lupron because LH, which triggers ovulation, is suppressed. This prevents a premature surge of the LH before the retrieval, which could cause loss of the cycle. Once the eggs are mature, an injection of Human chorionic gonadotropin (hCG) or LH is given to stimulate ovulation. Egg retrieval is scheduled 35 hours later.
B. Egg Retrieval:
this is the process used to remove the eggs from the ovaries so they can be fertilized.
the sperms are placed in a dish with the egg and left overnight in an incubator. Fertilization usually occurs on its own. However, sometimes, a single sperm is injected into an egg using a needle. This process is called intracytoplasmic sperm injection (ICSI). About 60% of IVF in the Unites States is performed with ICSI.Embryos that develop from IVF are placed into the uterus from 1 to 6 days after retrieval.
D. Embryo Transfer:
a long, thin tube will be inserted through the vagina and into the uterus and injects the embryo into the uterus. The embryo should implant into the lining of the uterus 6 to 10 days after retrieval.
Evidence of Acupuncture as an adjunct to IVF
Now, more and more evidence show acupuncture as an excellent adjunct to IVF. In one article published in Evidence Based Complement Alternative Medicine, 2012, Zheng, et al found out that Twenty-three trials ( a total of 5598 participants) indicate that acupuncture, especially around the time of the controlled ovarian hyperstimulation, improves pregnancy outcomes in women undergoing IVF.
(Evid Based Complement Alternat Med. 2012;2012:543924. doi: 10.1155/2012/543924. Epub 2012 Jul 2.
The role of acupuncture in assisted reproductive technology.
Zheng CH1, Zhang MM, Huang GY, Wang W.)
Another study also showed significant improvement of odds with acupuncture treatment.
Reprod Biomed Online. 2015 Jun;30(6):602-12. doi: 10.1016/j.rbmo.2015.02.005. Epub 2015 Feb 24.
Impact of whole systems traditional Chinese medicine on in-vitro fertilization outcomes.
Hullender Rubin LE1, Opsahl MS2, Wiemer KE2, Mist SD3, Caughey AB3.
The following acupuncture protocols are used to help IVF patients:
A. Lupron Routine:
to help suppress the luteinizing hormone (LH), and reduce the side effects of Lupron, Ganirelix or Cetrotide
1. Diji (SP8), Zhongji (Ren 3), Xuehai (SP6), Zusanli (St 36), Sanyinjiao (SP6), Hegu (LI4), Taicong (Lv3).
2. Cerebrum acupoints（HP-Zone）
B. FSH Routine:
to help stimulation of multiple eggs.
1. Cerebrum acupoints（HP-Zone）
3. Abdominal Zone:
Guanyuan (Ren 4),Zigong (EX Points)
Mingmen (DU4)，Shenshu (UB23), Eight Liao Points (UB31-UB34).
C. HCG Routine:
to improve the final maturation of the eggs
1. One day before egg retrieval: Neiguan (PC6) , Zusanli(St36), Pishu (UB20), Shenshu (UB23), Ganshu(UB18) , Diji (SP8), Taixi (Kid3), Taicong (Liv 3), Quchi (LI11).
2. Three hours before egg retrieval: Zigong (Extra Points), Sanyinjiao (SP6), Hegu(LI 4), Neiguan(PC6), Taicong(Liv 3), Quchi(LI11).
D. After Egg Retrieval:
Many patients showed the following symptoms, such as abdominal tender, emotional unsteady, headache, weight gain, nausea and sometimes vomiting, etc.
On the same day: Qihai (Ren 6), Shuidao (St 28), Daimai(GB26), Yinlingquan(Sp9), Sanyinjiao(SP6), Zusanli(St36), Xiaguan (St7), Quchi(LI11), Taicong(Liv3).
E. For the mobility and viability of Sperm:
Zhongji(Ren3), Guanyuan(Ren4), Zusanli(St36), Taixi(Kid3), Shenshu(UB23), Mingmen(Du 4), Dahe(Kid12), Sanyinjiao(SP6).
F. Before the Embryo Transfer:
For continues three days: Qihai(Ren6), Guanyuan(Ren7), Sanyinjiao(SP6), Zusanli(St36), Taixi(Kid3), Xuehai(Sp10), Pishu(UB20), Shenshu(UB23), and Ganshu(UB18).
G. After the Embryo Transfer:
Within 24 hours: Quchi(LI11), Neiguan(PC6), Sanyinjiao(SP6), Zusanli(St36), Taicong(Liv3).
Within 36 hours: Quchi(LI11), Zusanli(St36), Xuehai(Sp10), Diji(Sp8), Taixi(Kid3), Taicong(Liv3), Ear Shenmen, Ear Neifenmi, Ear Zigong.
H. After confirmed pregnancy:
Quchi(LI11), Zusanli(St36), Neiguan(PC6), Yinlingquan(Sp9), Taixi(Kid3), Taicong(Liv3), Ear Shenmen, Ear Neifenmi, Ear Stomach, until six weeks of pregnancy.
Some important acupuncture points:
Amy was scheduled to have hormone regulation (hormone treatment) for a month before trying to become pregnant again, and to have acupuncture treatments with me three times a week during that month.
After four weeks of treatment, Amy underwent the IVF procedure and was kept on the acupuncture treatment twice a week. Amy reported to me that she had eight eggs mature, a much improvement compared with the first IVF treatment which had produced only three mature eggs.
After a 48 to 72 hour culture, six of her eggs were fertilized and Amy’s doctor implanted four into the uterus. The doctor told her she should have bed rest overnight and that she could return to work the next day; however, I told her to have bed rest for two days, because Amy’s job is more stressful than most people’s, and she has to bend forward in her work to deliver babies.
A month after insemination Amy told me she was pregnant. She was very excited about her condition and eight months later delivered twins, a boy and a girl. She was thrilled with the results, as was her husband.
My personal experience:
1. In unexplained infertility, most of the cases are stress related. As an OB-GYN doctor, Amy worked very hard, as did her husband, and they had little time to be together. They are both under constant stress, their bodies always tight, in particular Amy’s uterus muscles. These factors made it very difficult for the fertilized eggs to attach themselves to the uterus. Some patients may be lucky enough to be pregnant; however, they may not retain their baby in the uterus because of the stress and tightness of their uteruses. They may have frequent miscarriages. My treatment is mainly for stress-reduction.
2. Many unexplained infertility patients have irregular hormone environments in their bodies because of their high stress levels. These will affect the patient’s entire reproductive system, such as Oocyte maturation, delivery, fertilization, implantation, etc. My acupuncture points are selected to adjust the hormone environment and make the different hormones harmony.
3. Each patient should have about one month of acupuncture treatment before starting the IVF procedure to prepare the patient’s hormonal system and to have her relax psychologically.
4. It is extremely important for the patient to have 48 hours of bed rest after insemination before taking up normal activities, because at this time the fertilized eggs are very weakly bound to the uterus. Any inappropriate movement during these first 48 hours might cause an early miscarriage.
5. For the key acupuncture points, you may do the acupressure by yourself as indicated above.
I thank Dr. Ming Jin, a professor from Shanghai University of Traditional Chinese Medicine, who gave me a lot of important input.