Infertility affects approximately one in 6 to 7 couples in the UK according to the World health organisation (WHO).
NHS statics shows that infertility is affected by age, physical or emotional condition and illness. Nowadays couples often delay having children until later because of the hectic nature of modern life.
Modern assisted reproductive therapies such as IVF or infertility medications bring some chances to couples to have children. IVF is only successful up to 35% at cases, its side effects such as financial strain, pain and discomfort from medication or scan, atopic pregnancy, multi pregnancy and miscarriage can put a lot of strain on the couple. Many people would welcome less aggressive alternative treatment without side effects.
Chinese medicine books recorded using acupuncture to treat infertility as early as 2000 years ago. There is plentiful anecdotal evidence of its effectiveness.
In order to bring a better outcome of IVF or show evidence that acupuncture is truly effective for infertility, the following research question emerged: Is acupuncture effective as an adjunctive therapy with IVF?
In order to answer this question, I will systematically review the relevant research that has done before, critically appraising the methods used in those studies and I will analyse their vigour in an effort to answer the research question or to present a new finding or to provide a recommendation.
Infertility is defined if a couple failed to conceive within 2 years of unprotected sexual intercourse. Infertility affects 3.5 million couples in the UK. There are two types of infertility: primary and secondary infertility (Infertility, WHO 2011).
Primary infertility occurs where the couple never have been pregnant; Secondary infertility affects couples that have previously been pregnant (Infertility, WHO 2011)..
Causes for infertility are various, for example: age, couples’ physical conditions, life styles, emotional strains or illness. Other reasons still remain unknown (Infertility, WHO 2011).
IVF (in vitro fertilisation) was used first to treat infertility in 1978 in the UK, followed by Austria. Now it is used by most of the countries all over the world (Winston, R M L 1993). It literally means that the egg is fertilised in glass in the laboratory. It is the most effective treatment in assisted reproductive therapies.
The process is precisely designed and comprises six distinct steps.
- Step 1: Controlling the natural monthly cycle: Most clinics use contraceptive pills followed by GnRH agonist Lupron to suppress the natural cycle, it takes about two weeks (HDIW 2011).
- Step 2: Stimulate multi- eggs supply: The ovaries are stimulated to produce multiple follicles by giving FSH (Follicle Stimulating Hormone), the dosage can vary significantly depending on age and ovarian function, the younger and healthier the lower the dosage, the older the higher the dosage. More eggs means the clinic could have more chance of using embryos for treatment. How many eggs are chosen depends on the age of the patient. For women over 40 years old, more eggs are chosen (HDIW 2011).
- Step 3: Operate the process: vaginal ultrasound and blood test are used to monitor the process and to ensure that the eggs chosen are mature. 33-38 hours before collecting the eggs, a hormone HCG Trigger (human chronic gonadotropin) is given to the patient (HDIW 2011).
- Step 4: Collect the eggs: A needle is inserted into the scanning probe and into each ovary to collect the follicular fluid containing eggs. Then the fluid is transferred to a special designed laboratory (HDIW 2011).
- Step 5: The eggs meet with the sperm: eggs are incubated with partner’s or donor’s sperm and cultured in the laboratory with nutrition supply (HDIW 2011)
- Step 6: Embryo transfer: embryo transfer (ET) is an outpatient procedure; it only takes a few minutes without any pain (HDIW 2011).
Not all clinics follow the 6 steps, and the steps they taken depend on the individual condition.
Side Effects of IVF
IVF brings the possibility for an infertile couple to have children, but the side effects exist in three aspects:
Infertility is a major life crisis for a couple. For women who want children but cannot be pregnant, it is a major blow. It shakes ideas about their femininity and self- esteem. For a man, it shakes his confidence. Going for IVF, involves an enormous intrusions to your personal life with problems being exposed to the outside world. All the stress and embarrassment inevitably put a lot of strain on marital relationships.
For a couple it might be a very hard time for them not only emotionally but also financially. IVF is a very expensive treatment and the success rate is low.
Possible risks throughout the procedure
During ovarian stimulation: the symptoms include swollen, painful ovaries, heartburn, gas, nausea or loss of appetite. In severe cases patients may have sudden excess abdominal pain, nausea, vomiting. During egg retrieval, it could have bowel and bladder infection, chest infection, allergic reactions to meds, or nerve damage (COF 2010).
During embryo transfer, if more than one embryo is transferred there’s always a risk of multiple pregnancy, there may be risk to the mother from such as premature delivery. Ectopic pregnancy may also occur where a fertilized egg develops outside the uterus. if this happens it requires immediate destruction of the foetus (COF 2010).
Miscarriage is also a great risk than natural birth. Birth defect has been a controversial topic in IVF, though there is no research to show that IVF could increase birth defect, but some researchers suggest that IVF could have more risk than natural birth. (COF 2010)
History and Theory
Bearing kids was considered as a woman’s duty. Childlessness was considered a tragedy in Chinese families in ancient times; so Chinese medical treatment for infertility started far long before any advent of modern assisted reproductive therapies.
Disorders of associated with female infertility were first recorded in the Chinese medical literatures 2000 years ago (Chen and li 2008). The treatise on Bone Hollow (Su Wen, Gu Kong Lun) in the Plain Questions states: ‘when the penetrating vessel is in dysfunction, women may present with infertility’; In Compendium Gold pieces Emergency Formulary (Qian Jing Yao Fang) uses the terms of childlessness or absence of pregnancy (cited by Chen and Li 2008).
The causes of infertility are also stated in different Chinese medical books in different period of time: Like the Treatise on Off Spring from Rare Book of the Stone House (Shi Shi Mi LU Zi Si Lun) discussed ten causes could lead to female infertility: it lists as uterine cold, spleen –stomach cold, urgent girdling vessel, depressed liver qi, exuberant phlegm-Qi, effulgent ministerial fire, debilitated kidney water, governing vessel disease, inhibited bladder qi transformation, and qi and blood deficiency. However, The Thousand Gold Pieces Emergency Formulary (Bei Ji Qian Jin Fang) pointed out that childlessness results from five taxations, seven damages or weakness and deficiency, it also states that infertility can lie with male as well as the female (Chen and Li, 2008) In a male controlled society to point out that infertility may result from a male deficiency could properly be regarded as a breakthrough in Chinese medicine history. According to the Sages’ Salvation Records insufficiency in the blood of the penetrating and conception vessels or kidney Qi deficiency can result in female infertility (Chen and Li, 2008).
Modern Causes of Infertility in TCM
Acupuncture has been long used to help women to achieve pregnancy in Asia, but acupuncture as an adjunctive treatment with IVF to treat infertility started in the very recent past.
Courses and Treatment Consideration
The major organs involve with infertility in TCM are kidney, liver, spleen and heart. The vessels mainly involve with conception and penetrating vessels. The patterns could involve Kidney Yin and Yang Deficiency, or Liver or Heart Qi stagnation, Blood Deficiency or Blood Stasis, or Damp Heat.
In order to give an accurate diagnosis and prognosis, woman’s period is considered an important indicator during the treatment, along with the patient’s constitution and age. The principle treatment may tonify kidneys, smooth liver Qi, calm down the house of Shen (Heart), strengthen Spleen and Stomach Qi to generate blood to the uterus and reproductive organs, nourish the penetrating and conception vessels and regulate menstruation.
Kidney governs reproductive function. Kidney stores essence (Jin) which is the original resource of reproduction. Kidney essence is getting weaker with age. Kidney Deficiency is viewed as the fundamental cause in many cases of infertility. It can involve Kidney yin deficiency or kidney yang deficiency or both deficiencies.
Kidney yang deficiency may result from congenital deficiency, kidney Qi deficiency and delayed or insufficient TianGui. The Su Wen Says:’ A women starts her period at the age of fourteen, when Ren Mai is unblocked and the pulse at Tai Chong LR3 is full, she is then capable of having children… at the age of forty-nine Ren Mai is empty, the pulse at Tai Chong LR3 is forceless. Menstruation is exhausted and she can’t have a child’ (cited by Zhang 1989).
A person with kidney yang deficiency may feel cold, have a pale complexion and lack of energy, the tongue is likely to be pale or even swollen and the pulse will be slow deep and weak. The treatment principle is to warm the kidney and uterus and to tonify the penetrating vessel.
Kidney yin deficiency may produce inner heat, the inner heat could dry out the moisten in uterus and conception and penetration vessels, therefore uterus and penetrating vessel and conception vessel could lack of nourishment, leading to dryness of vagina or malar fever, hot flush or night sweat. The kidney governs the penetrating and conception vessels; the penetrating vessel is the sea of the blood and the conception vessel governs the foetus. When such condition appears, it may lead to infertility. If a person with kidney yin deficiency, the tongue may be red but uncoated, the pulse may be rapid.
The treatment principle will reinforce the kidney, nourish the essence and benefit the penetrating and conception vessels.
Liver Qi or Heart Qi Stagnation
In cases of infertilities Qi stagnation may involve Liver Qi stagnation and Heart Qi stagnation in infertility. The Liver acts as free course of Qi and stores blood, the heart is the house of Shen and it governs blood. When liver Qi or heart Qi stagnation are present, the period may be scanty or heavy, if the stagnation is long term it may generate heat, heat could make the blood flow uncontrollably during menstruation or heat could consume fluid in blood. The heat also may invade to Uterus and penetrating and conception vessels could invade which may cause malnourishment to them resulting in infertility. The tongue of a person with liver Qi or heart Qi stagnation is likely to be red at the tip and sides. The pulse will be wiry. Treatment: Smooth liver Qi and calm down Shen and regulate period.
Spleen’s function is to transfer and transport fluid, when this function retarded it may result in dampness. Dampness may transfer to Damp Heat over a period of time. Internal Damp Heat may flow down to lower burner and affect the uterus and its channels. The dysfunction of Spleen could affect the function of stomach. Food stagnation could also cause dampness, damp heat will form subsequently. External dampness (from the environment) may also invade the penetrating and conception vessels directly. The conception and penetrating vessels could come obstructed by damp heat. Pregnancy may be impossible in such condition. In case of damp heat the tongue may be red with sticky coating, the pulse may be deep and slippery. Treatment is to tonify the function of Spleen, to resolve the dampness and to clear heat.
Blood deficiency and Blood stasis
Blood is the main source of menstruation, irregular period and infertility may result from the malnourishment of the uterus and conception and penetrating vessels. Blood deficiency always links to Qi deficiency, because Blood and Qi have a ‘mother and son’ relationship. When blood is deficient, blood stasis may result because Qi is relatively deficient. And blood deficiency relates to the function of Spleen and liver. Spleen is the resource of Blood and Liver stores blood. In some cases, in order to dispel blood stasis, some therapists may consider restoring Liver and Spleen function first. A person with Blood deficiency and blood stasis, the tongue may be purple or pale, the pulse may be weak and thin.
Treatment principles involve with dispelling of stasis, moving Qi, smoothing liver and tonifying spleen and stomach.
Research for acupuncture with IVF
Can acupuncture improve the outcome of IVF? In order to answer this question, an in depth critical appraisal of literature was undertaken to investigate the strength of evidence for and against the effectiveness of acupuncture assisting IVF.
Searches were made of Medline, Amed, books, and journals. The following key words were used for research: acupuncture, IVF, infertility, reproduction, hormone balance, FSH, LH and Chinese Medicine. In order to reflect the most recent and current information, only articles from the last 10 years were chosen for review.
Paulus et al (2002) conducted a randomised study on acupuncture and IVF to evaluate the effect of acupuncture on the pregnancy rate in assisting reproduction therapy (ART). Two groups were randomised: Group One was the acupuncture group, the other group (the Control Group) is the non-acupuncture group, there were 80 patient in each group, the Control Group only received IVF treatment, the acupuncture group received acupuncture treatment and IVF.
In Acupuncture Group, acupuncture was given before and after the Embryo Transfer. The results show that the acupuncture group the pregnancy rate was 42.5% (34 out of 80), however, the control group was 26.3% (21out of 80). It seems from this study that acupuncture is a useful tool for improving pregnancy rate after ART. However in this trial, there was no sham acupuncture (inserting needles but not relative points) to be chosen.
Paulus et al (2003) conducted another study the following year adding sham acupuncture as a control. The sham acupuncture pregnancy rate was 37% compared with 26.3% in the non-treatment control group of his previous study; indicating that the sham acupuncture may have had some effect (the rate for the real acupuncture group was 42.5%). Brandon et al (2007) suggest that more valuable information is attending through non-Placebo control group, otherwise, the result can be problematic.
Following the Paulus study, a vigorous pilot study designed by Quintero et al (2004) attempted to reproduce Paulus’ result using a randomised, sham controlled, crossover study. They found the trend towards higher implantation higher ongoing pregnancy rates in the treatment group, although the results were not statistical significant.
Magarelli et al (2004) did however found 42% in on-going pregnancy and reduction of miscarriage and ectopic pregnancy.
Another research was conducted by Westergaard and Cridennda (2004). 273 patients were randomised into three groups, Acupuncture Group 1, Acupuncture Group 2 and Control Group (no acupuncture treatment), Acupuncture 2 received the same treatment as Acupuncture Group 1 but received an additional treatment two days after embryo transfer. Compared to the Control group, the two groups had significantly higher clinical pregnancy rates (39%, 36% respectively compared to the Control Group 24%). Interestingly Group 2 had twice the rate of pregnancy loss of group 1 and the Control Group. It supports the traditional contradiction regarding SP6 (Shao Yin Jiao) and L14 (He Gu) and suggested that these points should be avoided after the ET.
Smith, et al (2006) designed a single-blinded, randomised controlled trial using sham acupuncture control to evaluate the effects of acupuncture on clinical pregnancy rates for women undergoing ET.
Women were randomly allocated to acupuncture or non-invasive sham acupuncture with a placebo needle (the Control Group). All women received three sessions of stimulating infertility, the first undertaken on day 9, the second before ET, and the third immediately after ET. The pregnancy rate was 31% in the Acupuncture Group and 23% in the Control Group. For those subjects receiving acupuncture, the odds of achieving a pregnancy were 1.5% higher than for the Control Group but the difference did not reach statistical significance.
Of the six clinical trials, only one (Smith et al 2006) was done by acupuncturist, others were conducted by physicians, nurses, Trained examiners, one study does not clarify the practitioner. The acupressure points were selected by protocol, instead of tailored patients. Points include PC6, SP8, LR3, GV20, ST29, ST36, SP6, SP10 and LI4, and only 2-3 sessions were given 1 or 2 days before the ET or afterwards. Does acupuncture really work for relaxation or for increasing the blood flow to uterus or increasing the release of the endorphin level? Would the results be different if the treatment has done by professional acupuncturist according to Symptoms? Macpherson et al (1997) said that differences in interpretation have always existed in oriental medicine. The practice of oriental medicine involves a dynamic interaction between practitioner and patient, which is shaped by the experience and intentions of the practitioner as well as the unique context of the patient. It is very difficult to draw a conclusion to say acupuncture works or not based on the designed protocol and unprofessional therapists.
To fully understand acupuncture as an adjunctive treatment with IVF, some studies have focused on the mechanisms of the treatment.
From Robinson & Hickenbottom (2003) at Cornell Medical Center reported that acupuncture increased the blood flow to the uterus, increasing endorphin levels, which effects gonadotropin-releasing hormone’s action, which regulates reproduction; lowers the stress hormones that can increase the chance of infertility; it impacts the plasma levels of the fertility hormones; it normalizes the hypothalamic pituitary-ovarian axis, which is important for hormonal balance; and it helps the polycystic ovarian syndrome. Such studies have done by Richer et al (2006) and Yu W et al (2007) mainly focus on the mechanisms of acupuncture treatment. Richer et al (2006) presented that acupuncture could affect the endometrial thickness.
Yu W et al (2007) reported that acupuncture was effective in thickening the uterine lining which increases the chance of reproduction.
Acupuncture with IVF has aroused of great deal of interest. Recent Western clinical trials have provided some evidence that acupuncture increases the chances of a successful outcome to IVF treatment. However the deficiencies of these trials limit the value of the evidence they have provided and a trial based on the Western scientific method may not be suitable for testing a treatment developed in the East in ancient times
Furthermore, the acupuncture practised in the West bears only a partial resemblance to that practised in China in the past and is very diverse in terms of style, type of practitioner and setting of delivery.
It is essential that an understanding is developed of the difference in practises between West and East. Further studies are required, using trained practitioners who are able to deliver treatment based on the need of patient. In addition practitioners should keep good records and involve themselves with acupuncture research, regardless of which theory they follow (Traditional Chinese theory or Five Element). The detail of each case in each clinic will form part of evidences we need find to test the effectiveness of acupuncture as a treatment for acupuncture.
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