Abstract
Abstract
Background:
Acupuncture and electroauriculotherapy treatments may enhance the success rate of the embryo implantation stage of in vitro fertilization (IVF) in the treatment of infertility due to hormonal imbalances.
Objective:
To examine the integrated approach of acupuncture and electroauriculotherapy as an adjunct to fertility medication and IVF.
Design, Setting, and Patient:
A case report of a 33-year-old woman who was in the beginning of her third IVF cycle, who presented to a private clinic and received a total of 8 treatments over a 1-month period.
Intervention:
Acupuncture, electroauriculotherapy, and nutritional supplements.
Main Outcome Measure:
Embryo implantation and pregnancy outcomes.
Results:
The patient achieved successful embryo implantation and full-term pregnancy. She did not need follow-up care after the treatment period. No complications occurred during pregnancy or at childbirth. No side effects were reported from acupuncture, electroauriculotherapy treatments, or supplements.
Conclusions:
Electroauriculotherapy and acupuncture appeared to be useful for this patient as an adjunctive therapy with IVF treatments and fertility medications.
Introduction
In vitro fertilization (IVF) is another alternative for some women who are unable to conceive. The clinical pregnancy success rate is 36% and a viable pregnancy rate is 29% per embryo transfer. 3 The IVF protocols begin by stimulating the ovaries with drugs to produce a number of eggs. These eggs are extracted by a needle, reunited with sperm in vitro, and incubated for 5 days, at which time 1 to several embryos are implanted in the uterine lining.
The Traditional Chinese Medicine (TCM) perspective of infertility falls under 2 general categories: deficiency and excess. The deficiency pattern is from the failure of TCM organs to nourish the uterus due to Kidney Yang, Kidney Yin, Kidney Jing, and Blood. The excess patterns are caused from an obstruction in the uterus such as Cold, Blood Heat, Dampness, Qi and Blood stagnation. 4 Most patients have a combination of deficiency and excess patterns. Encouraging the normal transition of Yin and Yang, and Qi and Blood, is the foundation of all successful TCM treatments for female infertility. 3
Infertility in China is treated in the 4 phases of the menstrual cycle: menstrual, postmenstrual, ovulation, and premenstrual. The treatment principles for the cycles include to move Blood and tonify Kidney Jing during menstruation, nourish Blood and Kidney Yin during postmenstruation, activate Qi, Blood, and supplement Kidney Essence during ovulation, and strengthen the Blood and Kidney Yang during premenstruation. According to TCM theory, Kidney deficiency can lead to multiple dysfunctions with the other organs. This imbalance can create a combination of deficiency and excess patterns with its interacting organs. 4
Case Report
A 33-year-old married woman presented with a diagnosis of primary infertility due to low progesterone levels and resulting anovulation. She also had elevated thyroid-stimulating hormone levels and was taking levothyroxine, 50 mg. Initial assessment revealed an overweight woman, 5′7″ in height. In TCM assessment, her complexion was pale and her tongue was dusky purple with a thin white coating. Both pulses were thready in the distal and middle positions and deep in the proximal positions. She reported stress from her diagnosis of infertility as well as from her job.
Western medicine treatments included initially receiving follitropin beta, 75 IU/d; menotropin, and ganirelix, 250 IU/d, with IVF for 2 cycles, which was unsuccessful. She was still taking these fertility drugs with the same doses and was beginning the third cycle when she commenced acupuncture. She sought and consented to acupuncture treatments.
Methods
The use of acupuncture and auriculotherapy were applied to different phases of the patient's menstrual cycle (menstrual, postmenstrual, ovulation, and premenstrual). The acupuncture points were needled bilaterally in supine for the first, second, and third weeks. In the fourth week, the patient was needled bilaterally in the prone position. In both positions, the needles were retained for 30 minutes. Acupuncture needles used for both positions were Seirin (Kyoto, Japan) 1-inch with 34-gauge diameter (because of the patient's needle sensitivity). Needles were inserted to depth of 15–30 mm, depending on the region of her body. Gentle clockwise manipulation was administered until De Qi was achieved.
Acupuncture Protocol
The core acupuncture points used were: Yin Tang CV 4, Zi Gong Xue ST 36, SP 6, LU 7, KI 6, PC 6, SP 4, and KI 3. In the first and second week of the menstrual cycle, GB 39 was added to nourish the marrow and essence. In the third and fourth weeks of the menstrual cycle, LV 3 and LI 4 were added for circulation. 5
Indirect moxibustion was then applied on CV 4 and Zi Gong Xue for 20 minutes during treatments in the first, second, and third weeks. In the fourth week of her cycle, a back treatment was given with points BL 15, BL 18, BL 23, and GV 4 to supplement Kidney Yang and nourish Blood. The same core points were also added to the back treatment with the exception of Yin Tang CV 4 and Zi Gong Xue. The indirect moxa was applied to BL 23 and GV 4 for 20 minutes to strengthen Kidney Yang.
Electroauriculotherapy Protocol
The auricular primary points were Uterus and Ovary from the Chinese system, Uterus and Ovary from the French system, Pelvic Girdle, Endocrine, and Shenmen. 6 The added points were Pituitary, Liver, Kidney, and Hypothalamus. The primary points and added points were used to increase the effects of hormone modulation in the hypothalamus-pituitary-ovary axis and to increase blood flow in the uterine lining. The auricular points were electrically stimulated with a Stimplus (High Springs, FL) hand-held device at Nogier Phase 1 pattern. The tender points were treated for 8 to 24 seconds. Stimulation was applied at a low intensity of 10 μA. (From past clinical experience, the small hand-held device works best at this frequency.) Nogier's theory of 7 different auricular frequencies was not applied in this case.
Supplements Used
Omega 3 fish oil, 400 mg, was taken once daily with meals, as were probiotics.
Results
After 8 acupuncture and electroauriculotherapy sessions, the patient was calm and ready for the embryo implantation procedure. She had a successful implantation and pregnancy progressed to term. The combination of Chinese medicine and Western medicine may have increased the chances for conception. There were no side effects from the acupuncture and electroauriculotherapy treatments. The patient's pregnancy and childbirth were free of complications; no treatment follow-ups were required during pregnancy. The fish oil and probiotics seemed helpful in reducing the irritation to the intestinal lining; her symptoms of abdominal bloating and constipation improved.
Discussion
The results achieved in this case support the theory that acupuncture and electroauriculotherapy may improve the chances of implantation with fertility medication and IVF. Initially, the patient underwent 2 cycles of fertility medication and IVF alone and did not achieve pregnancy. Electroauriculotherapy and acupuncture treatments for this patient with primary infertility appeared to be useful in successful implantation and pregnancy.
Successful IVF demands optimal endometrial receptivity at the time of embryo implantation. 2 Clinical pregnancy rates and implantation decline with increasing number of treatment cycles. After 3 cycles or more, clinical pregnancy drops to 29.4% and implantation rate drops to 12.6%. 2 This patient was beginning her third cycle when she sought adjunctive care.
The auricular points rationale was based on their organ function. The Pituitary point activates the release of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) to stimulate ovarian production to release hormones. The Ovary point stimulates the release of estrogen and progesterone for reproductive activity. The Hypothalamus point controls secretions of the pituitary gland by stimulating LH-releasing and FSH-releasing factors. The Liver point metabolizes hormones, regulates menses, and its Channel traverses the pelvic cavity. The Thyroid point balances metabolic activity; low or high thyroid functions have been related to infertility. The patient's high TSH levels required metabolic regulation. The Endocrine point activates the pituitary gland and brings endocrine hormones to appropriate homeostatic levels. 7 The Kidney point is based according to the Eastern view to strengthen constitutional weakness and essence of the body.
The Shenmen point calms the nervous system for balance of the autonomic system. Primary master points were used to intensify the physiological functions of the auricular points. Shenmen and Endocrine are both primary master points.
The auricular point Shenmen and the body point Yin Tang share the similar functions of tranquilizing the nervous system. The patient's conditions of infertility and a demanding job may have led to imbalances of the nervous system, causing stress. Stress can lead to a cascade of stress hormones causing unfavorable effects on the body. 1 Middlekauff found that acupuncture reduced stress through its sympathetic inhibitory properties, which impacts β-endorphin levels. 6 Petti et al reported that β-endorphin levels can influence ovulation and infertility. The β-endorphin is derived from its precursor protein pro-opiomelanocortin, which is present in the neuronal cells of the arcuate nucleus of the hypothalamus, pituitary, medulla and is also found in peripheral tissue including intestines and ovaries. 9 Simmons and Oleson reported scientific evidence that there was a neurophysiological and neurochemical basis for acupuncture and auriculotherapy in humans. 7
The Pelvic Cavity point relieves inflammation in the pelvic region and increases circulation. The Uterus point relieves inflammation of the uterine lining and increases proliferation of the endometrium. Uterus, Pelvic Cavity, and Liver points were used in combination to influence blood and lymphatic flow to the uterine lining for optimal implantation conditions. Endometrial thickness, morphology, and uterine artery blood flow have been implicated for successful implantation of the embryo. 10 The auricular points of Ovary, Pituitary, and Hypothalamus were used for their synergistic effects on the neuroendocrine system and hypothalamic-pituitary-ovarian axis. This axis impacts β-endorphin levels, which in turn affect the gonadotropin-releasing hormone secretions and the menstrual cycles. 11 The study by Aso et al revealed that acupuncture influences plasma levels of FSH, LH, endorphin, and substance P in women both with normal ovulation and also with anovulation. 12
The acupuncture point CV 4 is the intersecting point of the Kidney, Liver, and Spleen channels. Therefore, this point can potentiate the effects of other points on those channels. CV 4 strengthens the Kidney Qi and essence; Zi Gong Xue is used to tonify and regulate uterus functions; SP 6 is the intersecting point on the leg for the Spleen, Liver, and Kidney channels; SP 6 also gently moves and supplements the blood through all 3 channels.
In the Yin part of the cycle, the main emphasis is to keep estrogen levels balanced so that the uterine lining can proliferate, and glands in the cervix can produce fertile mucus. 3 The point LU 7 is the master point of the Directing Vessel and its coupled point is KI 6. All 6 Yin channels converge in the Conception Vessel, therefore allowing better distribution of Yin Qi in the body. 8 KI 6 nourishes Kidney Yin and is the master point of the Yin Qiao channel. The Yin Qiao channel travels to the brain and regulates its functions. 8 Studies show a correlation between various acupoints and specific functional areas of the brain. 5
The Conception Vessel has a considerable influence on menstruation because it supplies and moves the blood in the uterus. 8 SP 4 is the master point; PC 6 is the coupled point; the combination increases blood production in the uterus.
KI 3 nourishes Yin and Jing for constitutional weakness of the body. In TCM theory, if the Yin and Jing is deficient, the egg is not of optimum quality or quantity. 3 Kidney Jing and essence was nourished in all stages of menstruation with the points KI 3 and KI 6.
The duo points of LR 4 and LR 3 increase circulation by encouraging vascular and lymphatic flow throughout the body. The paired points also addressed the patient's Liver Qi stagnation symptoms of dusky tongue, wiry pulse, and stress.
In the Yang phase, the main emphasis is to keep the progesterone levels balanced so that the uterine lining is kept thick and receptive for the arrival of the embryo. 3 BL 23 and GV 4 were used on this patient to strengthen the Kidney Yang. BL 18 is the back Shu points of the liver; its action is to nourish liver blood. 5 BL 15 is the back Shu point of the heart; its function is to nourish heart blood and calm the spirit.
Moxibustion therapy was administered for warmth of the uterus. In TCM theory, the concept of warmth refers to an increase in metabolic activity with secretions of nutrients. This cascade of events maintains a highly nurturing home for the fetus. 3 Nutritional supplements were added to address the patient's intestinal problems of abdominal bloating and constipation.
Conclusions
Acupuncture and electroauriculotherapy appeared to be successful for this patient in enhancing the success rate of IVF treatment at the stage of embryo implantation. The 2 acupuncture methods were used at various times in the patient's menstrual cycle to strengthen her constitution and balance hormonal levels.
The results of this single-patient report should be verified in large-scale trials of acupuncture and electroauriculotherapy as complementary methods in patients undergoing IVF treatments.
Footnotes
Disclosure Statement
No competing financial interests exist.