back to course
TCM and Fertility Enhancement
This course is protected by U.S. copyright laws. Coping of any files on this site is absolutely prohibited. By checking the box below, you agree you have read and agree to terms and conditions specific to this course.
 

Image

Introduction

As more women and couples are facing infertility and more MD's are recognizing the benefits of acupuncture to help patients get pregnant, you as an acupuncturist are experiencing or will experience more demand for fertility assistance.  This course will hone your fertility enhancement skills whether working solely with TCM or in combination with Assisted Reproductive Technology.

The course material is a synthesis of over twelve years of my clinical practice and much additional study in the area of fertility enhancement and pregnancy care. My passion for reproductive health pre-dates my study of TCM, but the two were wed when as a graduate student, I first had the honor of studying with Raven Lang, acupuncturist and midwife.  Since that time, some of the other amazing writers and teachers who have influenced me include Dr. Randine Lewis, Mike Berkley, Dr. Daoshing Ni, Jane Lyttleton, Brandon Horn and Wendy Yu, and Giovanni Maciocia.

In this course you will find a review of the substances, organs and processes most involved with reproductive functioning and comparative Western and Eastern diagnoses.  Beyond theory, you will learn nuts and bolts like how to use basal body temperature charting as an effective tool for you and your patients, as well as herbal, nutritional and lifestyle gems.

TCM Substances and How They Relate to Reproduction

Yang:  Yang energy is needed for ovulation as it helps push the egg out.  It roughly corresponds to the hormone Progesterone.

Yin:  Yin is related to hormonal triggers that stimulate follicle development. It is connected to the health of the uterine lining and the function of the cervical glands which produce mucus. Yin roughly corresponds to the hormone Estrogen.

Blood:  Blood nourishes the endometrium and of course is connected to menses.

Jing:  This is considered “reproductive essence” and is inherited from parents and stored in the Kidneys.  It comes from both Kidney Yin and Yang. It is reflected in the development of the male and female reproductive organs and puberty, including menarche (the beginning of menstruation). One needs strong Jing for healthy eggs and sperm.

Shen:  The Shen encompasses higher spiritual levels and aspects of the brain and nervous system function. Shen is related to and controlled by the Heart. Stability of shen is needed for smooth a menstrual cycle.

Meridian/Organ Review Related to Fertility
 
Kidney:  Connects and encompasses the reproductive, skeletal, neurological and endocrine systems.  It is the root and support of all other organs and of Yin and Yang.  It stores Jing.

Spleen:  Transforms food to Qi and Blood. When under-functioning, Dampness and Phlegm can occur. It holds Blood and organs in place.

Liver:  Responsible for the flow of Qi throughout the system, and is needed for normal menstruation and ovulation.  Stress can impede the flow of Liver Qi, and affect areas of the Liver meridian including the pelvis and reproductive organs. Both Western and Eastern medicine see a connection to the liver and the metabolism and regulation of hormones. Stagnant Liver Qi can hinder a woman’s ability to adjust to the rapid hormone changes particularly after ovulation, which can result in PMS.  The Liver stores the Blood.

Heart (Bao vessel- "2 Hearts”):  The Heart Qi and Blood descend to the uterus to promote the discharge of eggs and the menstrual blood. The Heart and three of the extraordinary vessels - the Chong, Du and Ren - relate to the HPO (Hypothalamic-Pituitary-Ovarian) axis. This axis is the communication between the brain and ovaries and is responsible for ovulation. These extra channels also all originate between the kidneys and flow through the uterus.

Ren:  This extraordinary vessel is known as the Sea of all Yin. It arises between the kidneys and passes through the uterus to the perineum. Like the Chong vessel, it controls the menstrual cycle and plays an important role in conception and pregnancy (1).

Du:  Du, or Governing Vessel, helps control hormonal fluctuation and the menstrual cycle. It can also affect genital health as it circles the pubic bone and vagina (10).

Some acupuncturists believe that you must open the Dai Mai before working with the Ren and Du. An example of this would be to use the Master pt. GB 41 and local needles to open the pelvis, such as GB 27.
Image

Basal Body Temperature Charting (BBT) 

This technique is part of the Fertility Awareness Method which can help a woman avoid or achieve pregnancy. Other aspects include monitoring cervical mucus and cervical position. I will mostly be focusing on temperature charting, which I will refer to as BBT.

BBT can help show if ovulation is occurring, often indicated by a dip in temperature and then a rise that remains for at least three consecutive days. The Follicular phase (post-period and pre-ovulation) can vary in length, but the Luteal (post-ovulation) stage is consistent and is typically about 14 days. This will be discussed in greater detail.

A brief word about cervical mucus:  A woman is usually dry after her period, then moist and creamy and finally there should be slippery egg white-like mucus around ovulation, which is the fertile mucus. It is good to have intercourse each day there is fertile mucus and including the first morning of temperature rise.

How to administer BBT: A woman can use a basal body thermometer or a digital thermometer and will need to have a minimum of three hours of consecutive, restful sleep. The temperature must be taken first thing in the morning before she moves AT ALL. For example, no cuddling, stretching, or getting up to the use the restroom.

I suggest that my patients take their temperature at the same time each morning or to adjust the reading. If it is taken more than a half hour earlier or later than her base time, she should either add (if wakes earlier) or subtract (if sleeps in) one tenth of a degree for every half hour difference.

For example, let's suppose her usual waking time (base time) is 7 a.m.  On Saturday morning she sleeps in until 8:30. The thermometer reads 98.5, but she would circle/chart 98.2 since the time is 1.5 hours later than normal.

A person’s temperature normally elevates until about 4 p.m., hence the adjusting.

Temperature can also be affected by illness, alcohol, or sleeping embraced with a partner or child. These things should be added to the chart.

There are many wonderful resources for BBT charting including Taking Charge of Your Fertility by Toni Weschler. Other resources used for this course include writings by Dagmar Ehling and Katie Singer.

There are also phone and computer applications, such as “Fertility Friend” that can be helpful for patients to use.

Not all resources suggest making time adjustments, so see what works for you and your clients.

Below is an example of a normal BBT chart.  It shows a dip and rise in temperature at mid-cycle, which indicates that ovulation has occurred. This example shows a 28 day cycle, but it's normal for cycles to be anywhere between 21-35 days in length.

Normal BBT
Image

Assuming a 28 day cycle, each phase is about 7 days. Acupuncture and herbal protocols vary depending on the phase. It is important to write down the patient’s cycle day at each acupuncture visit. Day 1 of the cycle is the first day of menstrual flow (not spotting).

There is a simplistic correspondence between Yin (cooling and moistening) and Estrogen and Yang (warming and moving) and Progesterone.

Transformation between the phases and between Yin and Yang rely on smooth flow of Qi from the Heart and Liver.

Important Hormones

Follicle Stimulating Hormone (FSH):  Hormone produced and released by the pituitary gland in the brain that stimulates the ovary to ripen a follicle for ovulation.

Luteinizing Hormone (LH):  Also produced by the pituitary gland and acts to induce ovulation.

Human Chorionic Gonadotropin (HCG):   Released by placenta right after the embryo begins implanting in the uterine lining.

Estradiol:  Produced bythe  follicles in ovaries.

Progesterone:  Produced by the corpus luteum, which is formed by the follicle after the egg is released during ovulation.


Image

Phase 1 begins with the menses (days 1-5). The endometrium is shed and Yang is at its peak.  It rapidly declines and there is a transformation to the Yin. Qi and Blood move downward and the Chong begins to empty. Cramping and/or clotting indicates stagnation of Qi or Blood. 

During this phase, the BBT chart temperatures should be low.

Treatment is to move Liver Qi & invigorate the Blood (if stagnant). 
Points: Ren 3 or 4, St 28 or 29, Zi Gong Xue, Sp 8, 10, ear uterus, R Sp 4, L Per 6, Kid 14, Liv 3.

Herbs: If herbal medicine is warranted during this phase, I often use patents. Common formulas include Tong Jing Wan (Plum Flower's Calm in the Sea of Life) for cramping, Ge Xia Zhu Yu Wan for lots of stagnation, Tao Hong Si Wu Tang for mild stagnation with blood deficiency, or Wen Jing Tang to warm the uterus if there is cold present.

The treatment principle can also be to stop bleeding if it is very heavy.   In this case, suitable points would be:  Sp 8, Liv 5, Liv 6, Kid 5, Ki 8, and Moxa Sp 1.

Herbs: Treatment goals are to move blood and stop bleeding.  A good formula is Yunan Bai Yao/Tian Qi capsules or granules with herbs such as San Qi up 2-6g (steamed for Blood or Yin deficiency), Pu Huang (5-10g) Qian Cao Gen (6-15g), Di Yu (10-15g), and Xian He Cao (10-15g).
Image

This is the post-period phase, which can begin on cycle day 4-8. Blood and Yin are relatively empty. The quality of Yin effects the quality of the egg and the follicle around it. Yin and Blood are needed to regrow healthy endometrium.  At this this stage, there is more Estrogen than Progesterone.

BBT should still be low.

Treatment: It is important to tonify Blood and Kidney Yin (and sometimes to tonify the Spleen).

Points: Ren 4, UB 20, 21, 23, Du 4, Sp 6, Liv 8, St 36, Ren (Right Lu 7, Left Ki 6).

Patient can self-moxa lower Ren and/or St 36 during these days.

Here is a staple formula from Jane Lyttleton (1):

Gui Shao Di Huang Tang
Shu di  12g
Shan yao  10g
Shan zhu yu 10g
Fu ling  5g
Mu Dan pi 5g
Ze xie 5g
Dang gui 10g
Bai shao 10g

If there is a greater need for building blood, some helpful herbs are Dang Gui (3-12 g),  Gou Qi Zi (6-15g), He Shou Wu, which is also good for Yin and Jing (9-25g).

For Yin: Nu Zhen Zi (9-15g), Han Lian Cao (15-30g), Shan Zhu Yu (6-12g)

Spleen: Shan Yao (9-30g), Bai Zhu (3-12g)

In my herbal perscriptions I always include Chen Pi or Sha Ren to help the digestibilty of the formula.

It is important to start preparing the body for ovulation. If Yin is sufficient, you can increase Yang support starting around day 8-9 and definitely closer to ovulation, like Day 11 through Day 14/ovulation.

Sample Yang tonics: Tu Si Zi (9-15g),  Ba Ji Tian (6-15g), Xu Duan (9-15g)

Below is an example of a BBT chart you might see during this phase.  This chart illustrates two possible scenarios - overall high temperatures (typically temperatures decrease during menstruation) and an unsteady or "saw tooth" pattern with temperatures going up and down. If either show up on a chart, that could indicate Kidney Yin Xu with heat.  

page 5
Image

This is the ovulatory phase (days 11-16) and is under influence of FSH, Follicle Stimulating Hormone.  Follicles have been growing which contain eggs.  These follicles are releasing Estrogen. Yin is at its maximum and Yang begins to rise. A mid-cycle LH surge triggers events leading to ovulation within 24-36 hours. Once released, the egg will survive 12-24 hours.

BBT goes from low to high.

Treatment principle during this phase is to tonify Kidney Yang and to possibly move blood to promote ovulation. It is also helpful to move the Qi to aid the release of the egg and its smooth passage down the fallopian tube. In some cases, tonifying the Spleen and Resolving Dampness is in order.

Points: Ren 3, Ki 15 (1 cun below navel, .5 cun lateral), Sp 6, Extra Point Zi Gong Xue, GB 26.  Moxa Ki 3-7.

Patients can self-moxa Ki 3 & 7 during Phase 3 and 4.

Many patients use OPK/Ovulation predictor strips which shows the LH surge, thus predicting that ovulation is imminent.

In this phase, Jane Lyttleton recommends this formula to move blood and resolve stagnation (1): 

Cu Pai Luan Tang (Ovulation Decoction)
Dang gui 10g
Chi shao 10g
Chuan xiong 10 g
Hong hua 10g
Dan shen 10g
Ze lan 10g
Ji xue teng 15g

For deficiency of Yin or Yang, or an excess of Damp, please modify accordingly.
Image

In this post-ovulatory phase until menses or pregnancy, Progesterone is dominant. At ovulation, one egg is released and the remaining follicle becomes the corpus luteum which produces Progesterone to support implantation. The Yang continues to rise.

BBT should remain high. If it drops, then this most often indicates that fertilization did not take place and that the period is coming soon.

Spotting before flow can be due to Qi deficiency, Blood stagnation or excess Heat.

Treatment:  If there is a chance that conception has occurred, you must be careful with your herbal and point selection.  The general focus during this phase is to move Qi and Blood, resolve Damp Phlegm and Cold from the Uterus, and to support Yang.

If treating during pre-implantation time (less than 4 days after ovulation) or if there is no chance of pregnancy the following points can be used:  4 gates, St 28, Ren 3, 4, 6, Sp 6, GB 34, open Chong with Spleen 4 & Pericardium 6.

With possible pregnancy, no contraindicated points (LI 4, Sp 6, GB 21, UB 60 and 67, points on the lower abdomen and the lumbo-sacral area, such as UB 31 and 32).  As a general rule here, we don't want moving points or herbs.  You can use Moxa on Kidney 3 & 7.

Treatment principle is to tonify Kidney yang. It may be helpful to also gently move the Liver and/or to resolve Damp.

Modified You Gui Wan

Shu di
Shan yao
Shan zhu yu
Tu si zi
Ba ji tian
Lu jiao jiao

Take note that there now exists patent herbal preparations for each phase of the menstrual cycle.  Giovanni Maciocia, Jane Lyttleton, Golden Flower and others have formulas for the different phases.

Below are two examples of BBT charts you might see during this phase.  The first shows an unsteady or "saw tooth" pattern after ovulation/during the luteal phase can be showing stuck liver or heart energy, possibly with heat or fire.

Page 7 1















*


This next BBT chart shows a cycle that has a short luteal phase because there is less than 12 days past ovulation.

page

Image

Main Imbalances Involved with Infertility

Most patients are a combination of excess and deficiency and treatment of both Kidney Yin and Yang is key. Though there are some common Western and TCM associations, you cannot assume that one size fits all.

Jing Deficiency
Infertility due to a Jing deficiency is considered congenital as one is born or inherits this insufficiency.  Western examples include some types of amenorrhea including lack of menstruation due to premature menopause, or primary ovulatory failure can indicate that primordial follicles are not present.

Resistant ovaries means there are plenty of primordial follicles but they are not responding to stimulation that normally turns them into functional follicles which produce ripe eggs.

According to some practitioners, such as Brandon Horn, we can use post-natal essence to build prenatal essence and have a positive effect on the ovaries and follicles, thus helping to overcome a Jing Xu.

Kidney Yin Deficiency
This is especially seen in older women who are depleted. It may take many months to rebuild the Yin. The patient may be restless, anxious, find it difficult to get good sleep, flush easily (especially in late afternoon or evening), have night sweats, thirst (that they quench with sipping), scanty blood flow. The patient may be thin, wiry with dry skin and hair.

Weakness in pulse, tongue with little or no coat, cracks, and may be red.

Specific fertility related symptoms: The patient may have scanty fertile mucus and/or thin uterine lining. They may have an unsteady or short follicular phase BBT chart. The egg needs plenty of time to mature and lining needs time to thicken. A short or long follicular phase or temperatures that remain high can indicate Yin Xu with Heat.

According to Jane Lyttleton, the Kidney Yin Xu woman may have high FSH, be a poor responder to stimulation and need higher doses of medication and/or to be on a longer time. This can produce more anxiety, flushing side effects, etc.  It takes a long time for the ovaries to recover after this sort of stimulation (3).

Kidney Yang Deficiency 
This can arise from external cold invasion (such as Cold entering the Uterus) or overexertion that can weaken the Yang and create a deficiency.  Clinically you might see the patient retaining weight and/or water, have fatigue, low sex drive, low back and/or knee ache worse in cold weather, cold feet, and copious, pale urine. 

Pulse is typically slow and deep, tongue pale and swollen.

Specific fertility related symptoms:  Low BBT.  This can often lead to an inadequate luteal phase and manifest in the BBT chart with low overall temperatures, a slow, gradual rise in temperature, or the phase being too short.  Below is an example of a BBT chart you might see in someone with Kidney Yang Xu.

Kidney Yang Xu

















Spleen Qi/Yang Xu

This may be concurrent with kidney deficiency.  Symptoms are fatigue, loose stool, bruising easily, low appetite, bloating after meals and feeling of heaviness. This weakness can create excess damp in system.

Damp Phlegm Stagnation
This is a complex deficiency/excess pattern and most often develops out of Kidney/Spleen Yang deficiency. It manifests as a congealing of fluids at certain sites or in systems, disrupting function. Examples are ovarian cysts, including Polycystic Ovary Syndrome (PCOS), pituitary tumor, or tubal blockage.

Obesity or a heavy sensation. Pulse can be slippery, tongue swollen, pale, with sticky coating.

Specific fertility related symptoms: Period may be scanty and/or thick and mucusy and may come at irregular intervals. May have mid-cycle problems like pain, heaviness or bleeding. BBT may have kidney yang origins.   Client may have leukorrhea with actual little fertile mucus.

Damp combined with Heat
This may be an infection or heat/fire toxin, such as Pelvic Inflammatory Disease (PID).

Liver Qi Stagnation
Can be due to emotions, alcohol, coffee, smoking, rich foods.  Classic Liver Qi Stagnation signs are:  irritability, PMS (especially breast swelling and tenderness), headache, digestive disorders, waking 1-3 a.m., pulse wiry and tongue red, especially on sides if there is Liver heat/fire.

Specific fertility related symptoms:  Saw tooth pattern BBT.  Stagnation can lead to liver fire. Patient may be more irritable, get migraine headaches and/or have bloodshot eyes. This can lift luteal phase temperatures on BBT.  Caution with warming herbs and moxibustion.

Heart Qi Stagnation
Palpitations, anxiety, insomnia. The Heart communicates with the Uterus via the bao channel– this determines the growth and release of eggs. (Analogous to the HPO axis).  Tongue may have red tip.  Pulse thready or choppy.

Specific fertility related symptoms:  Irregular cycles or anovulation, which may be caused by emotional upset. You may see peaks and troughs on the BBT, similar to liver qi stagnation.

Blood Stagnation
Often a consequence of other disorders, such as Cold or Liver Qi stagnation.  When the Chong is not filled or emptied smoothly, there can be problems with the endometrium including clots, stop and start flow, or cramping. There may also be implantation difficulty and embryo rejection.

Pulse is choppy, tongue has a purple hue or spots.

Blood stagnation can be associated with endometriosis, uterine fibroids or polyps, or fallopian tube blockages.

BBT – when the Chong does not empty completely, the temperature may not fall with the start of a new cycle.
Image

Specific Western Diagnosis and TCM

Infertility, by definition, is when there has been regular, unprotected intercourse for 12 months without pregnancy.

Conditions that can contribute to infertility are:

Endometriosis
This is often Kidney deficiency with Blood stagnation and sometimes the presense of Phlegm, Heat or Cold. It is also helpful to resolve Liver stagnation to assist with Estrogen metabolism.

TCM treatment may need to be in conjunction with or after surgery.  There are many lifestyle, herbal and nutritional recommendations for this condition, many aimed at lowering inflammation in the body. A few examples are castor oil packs, eating organic, taking essential fatty acids (especially fish oil), reducing or omitting wheat, red meat, and foods that create sensitivity and inflammation.

Luteal Phase Defect
Evidenced as a luteal phase (time between ovulation and menstruation) that is less than 12 days in length.  There is also low serum Progesterone midway through the phase and spotting before menses.  The BBT would show lower overall temperatures or less substantial rise at ovulation.

TCM: Often need to tonify Kidney Yang and Spleen Qi. These patients may do fine with Clomid or exogenous Progesterone, however if they have Liver Qi stagnation with Heat, that can be exacerbated.

PCOS (Stein-Leventhal syndrome)
Symptoms: Irregular or absent periods, acne, obesity, hair growth, sugar metabolism issues, high blood lipids, cysts, and increased androgens that can block the release of mature eggs. Someone with PCOS cannot rely on LH predictor kits. If an egg is released it is often unhealthy and there is a higher risk of miscarriage. It is best to have at least three months of treatment.

In terms of Allopathic treatment, they are often prescribed Glucophage/Metformin, which addresses blood sugar metabolism.

TCM diagnosis may be Qi stagnation and/or deficiency leading to damp accumulation or Phlegm Damp with Kid Yang deficiency. It is important to work with Spleen, Liver and diet.

Herbs: Zao Jia Ci before ovulation, and focus on moving blood during ovulation.

There was as a study in the 1990’s in Europe using electroacupuncture for anovulatory PCOS – ovulation was restored in 1/3 of subjects (2).

Advanced Maternal Age
Once a woman is over 35, it may be advisable to give treatment twice per week.

Even though DNA is less stable over time, eggs do not have an expiration date!  What makes them less responsive is hormonal fluctuations. The problem with IVF is that it only addresses the last few weeks of an eggs journey from initial follicle to released egg. Western medicine hyper-stimulates the ovaries, which does not address the root of age-related infertility: imbalances with the HPO axis, reduced blood flow to the ovaries, and the internal environment which affects follicular development over the months prior to ovulation. It takes up to 150 days for an egg to go from resting to being ready for release.

A study with mice confirmed the belief that the ovary contains deep, hidden stem cells, capable of becoming new eggs. It was previously believed that a woman's ovarian potential was determined before birth, and was incapable of being improved upon.

The ovaries respond to cues from the internal environment (the blood circulation, hormones, nutritional status, oxygenation, stress hormones in the blood, toxin and antioxidant levels) and create a follicular environment to mimic the body's internal response to its external environment. It is within that follicular environment that the eggs (which have been in a dormant state since before birth) undergo meiosis, and wait to see if they will be selected for maturation and ovulation.  TCM can help improve this internal environment - improving egg quality and also potentially helping the body call upon these dormant eggs.

Brandon Horn and Wendy Yu teach that ovarian aging is not about age, but damage.

The use of CoQ10 can also help with ovarian health.

One consideration is that when there is high FSH it can be brought down with Yin tonification and/or Estrogren, but this may not be addressing the real issue.

Image

Male Factors/ Sperm Health

A healthy semen analysis would show the following:
Volume:  More than 1 ml
Count:  More than 20 million per ml.  The average is 500 million sperm in one ejaculation.  Decrease in counts is linked to environmental pollution.
Motility:  More than 50% moving vigorously and purposefully
Morphology:  More than 14% Normal forms (no deformities)

During IVF, a process called ICSI (intracytoplasmic sperm injection) can be utilized. Sperm is injected directly into the cytoplasm of the harvested egg. This is helpful for low sperm count or motility, or if there are antibodies.

It takes approximately 2.5 months (70 days) to make sperm so the patient needs to allow time for nutritional changes, supplementation and treatment to show full benefit.

Main TCM etiologies:
Poor count:  Kidney Yin with Heat
Low volume and motility:  Yang (impotence, low libido).  As with women, it is often necessary to treat both Yin and Yang.
Infections:  Damp-heat
Inflammation, Varicocele:  A varicose vein in scrotum which allows body temperature to rise and blood to spill backwards from abdomen. The raised temperature in the sperm-making cells makes them malfunction, lowering count. Surgery may be needed.  This is considered both Blood and Qi stagnation.

General Recommendations:
It is important to ejaculate at least once a month, and every other day from day 10-18 of a woman’s 28 day cycle. Less frequent ejaculations make more viscous fluid and slow down the sperm. More frequent ejaculation reduces sperm count.

Keep body weight in a normal range. Fat cells convert androgens to estrogens which can interfere with male hormone balance. Low weight impedes sperm production.

Most vaginal lubricants are hostile to sperm. The product “Pre-Seed” is not hostile.

There is debate about the scrotal temperature issue.  To be on the safe side, boxers instead of briefs may be a better choice, as is keeping Jacuzzi use to a minimum.

Substances to Avoid:
Alcohol:  Contributes to poor sperm quality, count and motility.
Marijuana:  Linked to poor production and motility.
Cigarettes:  Reduces count and may impede proper formation.
Coffee:   Linked to poor motility & restricts circulation to the extremities (including the genitals).
Toxic chemical exposure:  Pesticides, heavy metals, paints, solvents etc. wreak havoc on the reproductive system. Taking the herb Milk Thistle can help detoxify the liver.

Avoid synthetic estrogens found in conventional meat and produce.  Buy organic fruit & vegetables from the Farmer’s Market or grocery store.

Avoid dampening foods like sugar, white flour products, fried foods, excess dairy.

Eat plenty of foods high in vitamin A  such as asparagus, broccoli, fish, parsley, apricots, cantaloupe, pumpkin, papayas, yellow squash, garlic, carrots, sweet potatoes, spinach, swiss chard, kale, romaine lettuce and other greens.

Suggested Supplements:
Vitamin C: 500 mg/day in divided doses (buffered/Esther C)
Vitamin E:  400 IU/day (buy d-alphatocopherol NOT DL-alpha, which is synthetic)
Beta-carotene (source of Vitamin A):  25,000-50,000 IU/day (good to have mixed carotenes)
Zinc:  50-60 mg/day (helps with sperm production)
L-Arginine:  1500-3000 mg-4g/day (If no Herpes)
Folic Acid:  800-1600 mcg/day
Vitamin B12:  400-800 mcg/day (especially important for vegetarians)
Make sure your antioxidant formula also includes Selenium (200 mcg) and B5 (100-200mg/day).

If motility is an issue, take 500-1000 mg of L-Carnitine/day

Because of sperm’s susceptibility to oxidative damage, it is helpful to include free radical scavengers like grape seed extract (not to be confused with grapefruit seed extract).

For motility issues, have the man come in shortly before his partner’s ovulation.



Miscarriage

TCM can be helpful with the following conditions surrounding miscarriage:

1.    Threatened miscarriage by means of “pacifying the fetus.” Threatened miscarriage can be due to Kidney deficiency, Qi deficiency, or Heat in blood affecting Liver and Heart, disrupting the Bao and creating an untimely opening of the uterus. It can also be due to Blood stagnation.

2.    If indeed a miscarriage is inevitable, or has just occurred, TCM can expedite removal of uterine contents. Afterwards you can tonify the blood and calm shen/reduce stress, and help to regulate cycles again.

3.     Prevention for recurrent miscarriages (3 or more miscarriages) – If a patient is very deficient, especially in Yin, it is important to allow time for rebuilding. The goal is a healthy pregnancy and baby, not just getting pregnant. This is also true from the beginning of fertility treatment.

Recurrent miscarriage can be due to cervical incompetence or low progesterone.  TCM treatment would aim at boosting Spleen and Kidney Yang. There is no treatment for genetic abnormalities.

There may be an autoimmune component to miscarriage.  Specific blood markers can show if a woman is prone to blood clotting in the placenta. Blood thinners or corticosteroids may be prescribed to override this and to allow implantation.

Some women feel fluttering or tugging in the uterus and may have fever, rash or other immune type symptoms. You can treat reaction to implantation by moving blood, clearing heat from the blood and/or Damp heat from uterus.

Horn and Yu suggest the use of Divergent channels for autoimmune conditions.

Image

Reproductive Health Diet and Lifestyle

Toxicity
As mentioned elsewhere, it is important to eat organic foods and to beware of environmental sources of Estrogen and xeno-estrogrens - pesticides, herbicides, plastics and solvents. Avoid plastic for drinking, microwave heating in Tupperware or with plastic wrap. Avoid growth hormone in conventional meat and dairy and PCBs (Polychlorinated biphenyls) in fish and duck (4).

Dioxins
Bleached products including tampons and toilet paper, gas and power generating facilities. Most exposure is due to accumulation in fat in animal tissue, therefore it is recommended to eat leaner cuts. It is also helpful to get good fats through cleaned fish oil, coconut, extra virgin olive oil.
Dioxin toxicity can promote endometriosis, reduce FSH receptors, cause anovulation and ovarian dysfunction.

Mercury 
Present in amalgams (fillings), seafood, Preparation H, spermicides, vaccines, fluorescent lights, contact lens solution, make-up, skin creams.
Mercury toxicity can cause increased risk for miscarriage and defects.

But even with environmental/oxidative stress, it is important to not over-do anti-oxidants like Vitamins C and E. The inflammatory response shares a number of common mechanisms with fertility and conception. This is why a women should avoid NSAIDS during ovulation.
Image

Specific Recommendations to Promote Fertility

To enhance Jing, beneficial foods include eggs, nuts, seeds, animal organs, marrow, oysters, seaweed, oats, raw milk.

Yin is related to the parasympathetic nervous system.  For both Jing and Yin, the person needs "down time" and to balance from overly stimulating and rushed lifestyles. Meditation, tai chi, walks in nature, especially the ocean are beneficial.  For these patients, avoiding long hours in front of computers and other electrical devices, which drains and dries the body needs to be implemented.  Stimulants like spicy foods and coffee should be reigned in.  Helpful foods include barley, millet, string beans, asparagus, dark beans, dark fruits like black or blueberry, seaweed, chlorella, spirulina, animal products, soy, flax, and Royal jelly.  Essential fatty acids are good for follicle rupture & collapse, which then forms corpus luteum.  Hydration is a must (no saunas, bikram/hot yoga).

If one has a good Yin base, then Yang energy benefits from movement and stimulation.  Consuming warm foods prepared by baking or simmering using ginger, cinnamon, shallots, animal products etc. is a good nutritional start.  Warm baths, hot water bottles, and keeping feet warm like soaking in hot water can go along way. Foot soaking can also bring more blood circulation to the pelvis.  Coffee consumes yang and should be avoided.

For patients with a more Spleen Qi deficient consitution, eating meals regularly which are cooked and foods that are warming is key.  Absolutely no iced beverages and avoid simple carbohydrates, sugar, dairy, and fruit juice.  Helpful foods for this constitutional type are aduki beans, chick peas, rest, not over-exercising, and meditation to reduce worry.

Blood deficient patients should consume hormone-free meat, poultry, soup from bones, egg yolks, legumes, green leafy vegetables, beets, and spirulina.
To prevent blood stagnation, avoid hydrogenated oils, sleeping with tampons, intercourse during menses, cold entering uterus.  Examples of cold entering the uterus are swimming, camping, or eating cold foods right before or during the period.

To increase blood and/or qi circulation, breathing exercises like qi gong, or movements such as belly dancing or massage, including Mayan abdominal massage or Chi Nei Tsang, Chinese Abdominal massage, is a great idea. Some movement and massage should only be done during the follicular phase if there is a chance of pregnancy.

To enhance liver function, avoid overeating, alcohol, coffee, smoking, and additives/preservatives.
To soothe the Liver, appropriate emotional expression, exercise, and hot lemon water can yield wonders.

Some practitioners have very specific dietary guidelines for their fertility patients. Angela Wu from San Francisco, Ca. outlines the following recommendations in her book Fertility Wisdom (5):
- No raw foods, processed foods, alcohol, caffeine, soda, chocolate, sweets (honey ok) including fruit juice and fruit including avocados, olives and tomatoes. No shellfish, pork, mung beans, no poultry during pre-ovulation time, no wheat, gluten, millet, brown rice. One can use white rice, oat, spelt, kamut flour.
- Only allowed dairy is butter, goats milk, cottage cheese. No cheese - even if soy, goat, rice or almond.
- No rooted veggies (carrot, turnip, potato, yam, beet) or cooling veggies (corn, eggplant, cucumber, cauliflower, squash, seaweed, including miso).
- No sage for cooking. No mint drinks or chamomile tea.
- Hot/spicy/pungent foods OK, pre-ovulation only.
- Men must follow same guidelines during the pre-ovulation phase of their partner.
Image

Mind/Body/Spirit

When we are stressed and go into fight or flight mode (the sympathetic branch of the nervous system), blood flow is redistributed away from the gastro-intestinal, endocrine and reproductive systems. Adrenaline inhibits utilization of Progesterone. Nature knows that it is not a good time for pregnancy.
Studies connect stress to infertility through hormone imbalance, ovulation irregularities, and abnormal sperm development.

Because many of our patients experience regular stress, including trying to get pregnant, it is very important to teach or recommend tai qi, meditation, yoga etc.

There is also a wonderful, non-invasive mind/body therapy that provides a neurological re-boot for patients with chronic stress and other health issues that I have found clinically to be helpful. To learn more about B.E.S.T. (Bio-Energetic Synchronization Technique), go to Morter.com.

Image

Assisted Reproductive Technology (ART)

ART refers to all fertility treatments in which both eggs and sperm are handled.

Intrauterine Insemination (IUI):  Clomid is often prescribed, which blocks the action of Estrogen so that the pituitary is tricked into releasing more FSH to stimulate follicle growth. Multiple eggs are released, which increases the chance of a multiple (ie, twins) pregnancy. The sperm is washed and the best of the best is injected into uterus. IUI can be helpful for endometriosis, mild male factor or cervical factor, though it is most commonly used for unexplained infertility. This is much less expensive than IVF.

In Vitro Fertilization (IVF):  Prior to the IVF cycle, the woman is given down regulating drugs like Lupron to prevent pituitary gland function. It is important to be careful with herbal use during this time. After the period, drugs are given to stimulate follicles and two weeks later, the eggs are harvested (OPU – oocyte pick up) through the vaginal wall. The eggs are combined with sperm collected two hours prior. Three to five days later 1-2 embryos (or more) are placed in the womb with the hopes of implantation.  If there are additional embryos from the cycle, they can be frozen for later cycles (FET - Frozen Embryo Transfer).

The studies regarding using acupuncture before and after IVF were done 25 minutes before and after the procedure. Some acupuncturists will treat directly in the IVF clinic. Others will treat in their own office the night before transfer and then do a home visit shortly after the patient returns home. Patients are often told to remain on bed rest for a couple of days so it is helpful to go to them.

After the transfer, the patient is also given Progesterone and Estrogen.

Some women, especially if there is a history of miscarriage, will elect to do Pre-implantation Genetic Diagnosis, or PGD. Many women in their 40's and certainly in their 50's are using donor eggs. Now more women are freezing their eggs for future use.

Ideally we would have three months to give TCM treatment before the procedure but this opportunity is rarely given. Most RE's (Reproductive Endocrinologists) do not want their patients taking herbs - especially once stimulation begins. And they often frown upon the use of estrogenic herbs while the patient is taking the pill or Lupron to quiet her system.

In terms of acupuncture precaution, be aware of too much movement/circulation around egg retrieval time. For example, if you have been using elecro-stimulation, Dr. Dao suggests you stop when the eggs reach 18-20 mm so that you do not cause ovulation.
Image

Fertility Medications

Clomid
This oral medication is used to correct irregular ovulation, increase egg production and correct luteal phase defect. It prevents the pituitary from perceiving circulating estrogen levels. Side effects – Headache, nausea, lack of fertile mucus, moodiness. This medication is heating and can be beneficial with Kidney yang deficiency, but can exacerbate yin xu or liver qi stagnation with heat (2).

FSH prep (Gonal-F daily injection) bypasses the pituitary and stimulates the ovaries directly. Side effects include abdominal pain and nausea. In TCM, this causes stagnant liver qi and damp accumulation.

The stimulation medications can cause ovarian hyperstimulation syndrome (OHHS). The body releases fluid outside of the blood vessels, and the belly swells. For prevention and to address during, it’s helpful to eat protein, avoid simple carbohydrates, stay hydrated and support electrolyte balance. If the hyperstimulation is not resolved, they will freeze the embryos for a later transfer.

Women with PCOS are often on which helps control blood sugar, but can seriously undermine a Spleen deficiency so a spleen tonic can be beneficial.

Image

TCM and ART: Mutually Beneficial

TCM can improve the outcome of IVF by:

    1.    Alleviating side effects of treatments and medication, such as headaches, bloating and irritability.

    2.    Improving the response to hormone stimulation.

    3.    Improving blood flow to uterus/endometrium and ovaries.  A Swedish study by Stener-Victorin (6), printed in Human Reproduction in 1996 showed that electroacupuncture on UB 23, 28 and between Sp 6 and UB 57 for 8 treatments total, performed twice a week lowered high uterine artery blood flow impedence on pulsatility index (it increased blood flow to the uterine arteries).

    4.    Alleviating tension/stress.

    5.    Calming the uterus to prepare it for implantation.

    6.    Reducing the risk of miscarriage and helping the woman achieve a full term pregnancy and delivery.  Retroactive study of 131 women with the protocol  listed above showed no significant difference in pregnancy rates, but the live birth rate was significantly higher. Miscarriage was almost cut in half.

    7.    Improve sperm count and motility

An article in Fertility and Sterility in 2003, featured the work of several MDs including Dr. Raymond Chang of Weill Cornell Medical Center (NY-Presbyterian Hospital) who summarized the current research that supported acupuncture’s potential benefits for fertility treatment (9). They reported:
-Increased blood flow to uterus and adding to wall thickness
-Increased endorphin production, which in turn effects the release of gonadotropin-releasing hormone (GnRH)
-Lower stress hormones responsible for infertility
-Impact of plasma levels of FSH, LH, E2, P4
-Normalization of the HPO-axis
-A positive effect for women with PCOS

In May 2007 Diane Cridenna, L.Ac. and Dr. Magrelli examined data collected over four years to determine if there was any effect on the outcomes of patients who combined IVF with the two study protocols. They used the Stener-Victorin protocol and Paulus protocol.  The pre-ET (embryo transfer) treatment occurred 12-24 hours before transfer. After the treatment, press tacks were placed in the same pattern and the patient was instructed to stimulate them during the transfer. The second treatment was an hour post- ET. New press tacks were placed, then removed in three days.

After 4 years they reviewed results with 216 patients. There was 61.1% pregnancy rate in the acupuncture group vs. 37.4% in the non-acupuncture group. Also, there were significantly fewer ectopic pregnancies. They suggest that the ideal number of treatments prior to embryo transfer is nine.

More information is available on Cridennda’s website: www.eastwindsacupuncture.com

Because of these and other studies, more and more Reproductive Endocrinologists are suggesting acupuncture for their clients. In fact, many fertility clinics have acupuncturists on staff or have a healthy cross-referral system between their clinic and local acupuncturists. They typically find that their patients that receive treatment are more relaxed/less stressed, have fewer side effects, and better outcomes.


Image

Acupuncture IVF Protocol

A German study led by Wofgang Paulus and published in 2002 in The Journal of Fertility and Sterility. 80 patients in the control group did not receive acupuncture and 80 women did receive acupuncture 25 minutes before transfer and again 25 minutes after transfer. 42% of the women who received acupuncture became pregnant, compared to 26% of patients who did not receive acupuncture.

Points before:
Per 6 - calms,  Bao luo connects the Heart to the Uterus
Sp 8 - resolve blood stasis in uterus/minimize cramping and treat abdominal distension
Liv 3 - connects with Ren 3 & 4 to allow free flow of qi to move blood into uterus
Du 20 - Calm shen and move qi upward to assist holding/implantation
St. 29 - warm uterus, treat inflammation of the fallopian tubes

Ear shen men and uterus on one side and Brain and Endocrine on the other
Influences uterus and stabilizes endocrine system. Sedates sympathetic response to further calm the spirit.

Points after: (main benefit is to prevent cramping)
St 36 - Support qi, can regulate qi and blood to prevent cramping
Sp 6 - helps Spleen hold Blood, harmonize liver, spleen and kidney which all communicate with uterus
Sp 10 - IVF can lead to blood stasis
LI 4 - Because uterus is vulnerable to contractions after an embryo transfer, helps to relax the uterus

The same ear points as before the transfer, but on the opposite sides.

According to Reproductive Endocrinologist Dr. Paul Magrelli - “This protocol has demonstrated reductions in contractility, so by relaxing the uterus before transfer and immediately after, we felt we were setting up a better environment for implantation."

Some practitioners will perform a “holding treatment” four or five days after the transfer. I offer this as an option and will typically do Du 20, Sp 9, Stomach 36, Shen points, such as Yin Tang, and will do moxabustion at Sp 3 and Kidney 3 and 7.


Image

Conclusion

If your patient achieves pregnancy, continued care with TCM can be very helpful for nausea and other common pregnancy-related issues.  Acupuncture can also be beneficial towards the end of pregnancy to help prepare for labor. 

As demonstrated in this course, Chinese medicine can be used as a stand alone treatment or in conjunction with ART to increase the likelihood of pregnancy.  As technological advancement continues in the area of reproductive medicine, there will always be a place for our ancient, effective and balancing methods.  You are encouraged to come back to this course time and time again, during whatever phase you are treating, for clarification and guidance when navigating the sea of infertility. 

May you and your patients have much successs! 

References

1.  Lyttleton, J. (2004). Treatment of Infertility with Chinese Medicine. New York: Elsevier Ltd.

2.  Lewis, R. (2004). The Infertility Cure. Boston: Little, Brown and Company.

3.  Lyttleton, Jane. IVF and TCM. (Last visited April 18, 2010). Available online at prodseminars.net

4.  Horn, Brandon and Wendy Yu. Optimizing Ovarian Reserve. (Last visited March, 12, 2012). Available online at prodseminars.net.

5.  Wu, Angela. (2006). Fertility Wisdom. Rodale Inc.

6.  Stener-Victorin et al. Hum Reprod. 1996 Jun;11(6):1314-7. Reduction of blood flow impedance in the uterine arteries of infertile women with electro-acupupuncture.

7.  Paulus, et al. Fertility and Sterility Vol: 77, No. 4 April 2002. Influence of acupuncture on the pregnancy rate in patients who undergo assisted reproduction therapy.

8.  Cridennda, Diana and Paul Magarelli, M.D. Research presented at ASRM 2007.     Acupuncture in IVF Linked to Lower Miscarriage and Ectopic Rates. A(Last visited May 3, 2013). Available online at eastwindsacupuncture.com.

9.  Chang, et al. Fertility and Sterility Vol: 78, No. 6 December 2002. Role of    acupuncture in the treatment of female infertility.

10.  Maciocia, Giovanni. (1998). Obstetrics and Gynecology in Chinese Medicine. New York: Churchill Livingstone.

11.  Kass-Annesse, Barbara and Hal C. Danzer, M.D. (1992) The Fertility Awareness Handbook. Alameda: Hunter House.

12.  Ehling, Dagmar and Katie Singer. Alternative Therapies in Health and Medicine,  November, 1999, Vol. 5, No. 6, pgs 70-83. Gauging a Woman’s Health By Her Fertility Signals: Integrating Western with Traditional Chinese Medical Observations.
 

 
 
 
 
Login | Register