Abstract
Morning Sickness
While on a medical visit to China in the 1980s, Dundee watched prospective mothers in an antenatal clinic being taught acupressure at the PC 6 point to reduce or avoid the morning sickness that accompanies more than 80% of pregnancies. On his return to Belfast, Northern Ireland, he set up a controlled trial with colleagues demonstrating that PC 6 acupressure was an effective and safe mode of treatment. 1 I follow his lead in teaching acupressure to be applied by patients when waking every morning in the early antenatal months. To get maximal benefit it is important for the patient to apply the acupressure before getting out of bed and before the nausea starts.
An easy way for women to find PC 6 is to run a finger from the midline of the palm until it slips into the soft hollow proximal to the hard flexor retinaculum. As this is directly over the median nerve, firm pressure can be uncomfortable. So, I recommend using bilateral PC 6 wrist bands that are commercially sold inexpensively for seasickness. 2 Additionally, I suggest taking ginger in some form, either in a drink or biscuits.
If morning sickness has already progressed to the point of true hyperemesis gravidarum, patients have been able to avoid hospitalization when I have added daily needle acupuncture at both PC 6 and LR 3, with the additional stimulation usually providing sufficient control.
Back Pain
Traditionally, acupuncture at certain “forbidden” points has been discouraged during pregnancy. 3 However, no evidence of serious harm to a pregnancy has been reported in Western medical literature, although this might be because acupuncture at these points has generally been avoided. 4 Cummings argues that, due to the need to avoid medication during pregnancy, acupuncture can seem the most viable option for addressing some problems, 5 with low-back pain being the most common one. Thus, acupuncture should be offered after a full discussion about theoretical risks and practical benefits. Nonetheless, any contraction-like sensations should warrant discontinuation of the acupuncture. 6
In accordance with tradition, I do try to avoid the stronger forbidden points and maintain a low level of stimulation with a minimum of necessary needles. I approach back pain in pregnancy via local tender spots, needling into the muscle, plus BL 27 over the sacroiliac joints together with points in muscle under the iliac crest. Huatuojiaji points are often tender, and I use them to apply gentle periosteal tapping onto the vertebrae. 7 My initial treatments are purely manual, but I may progress to electroacupuncture (EA), as this is often soothing and is regarded as more effective for back pain.
Induction of Labor
If an obstetrician says that a patient must deliver within a few days or she will require chemical/surgical induction or cesarean section, then immediate acupuncture induction should be attempted. Controlled-trial evidence suggests that acupuncture for induction of labor is safe, with no adverse fetal effects, and could be effective, particularly in terms of cervical ripening, which would make any necessary further, more-intrusive methods of induction less traumatic. 8
SP 6 is regarded as a general gynecologic point, is also one of the most accepted of the forbidden points, and has been used to induce early abortion. SP 6 has been featured as an important point in almost all controlled trials of induction, in one case as the sole point used. 9 This, then, is my preferred point.
Initially, I give telephone instructions to the patient (or consort) to start acupressure in the SP 6 area. I describe taking a hand's breadth up the inside of the leg from the bony prominence of the medial malleolus and feeling along the posterior edge of the tibia to find the most tender spot. This might not be at the anatomical SP 6 point, but it is the tenderness that is important, not the formal point identification. 10 I will then see the patient twice per day for needle acupuncture bilaterally at the maximally tender point in the area of SP 6. I use deep needling into the muscle with manual stimulation intermittently for ∼10 minutes and I suggest that the patient continue with acupressure at intervals between acupuncture sessions until delivery or alternative medical intervention becomes necessary. There is some evidence that maintaining acupressure during contractions can be an aid to the management of pain. 11
Cesarean-Scar Pain
Although opiate medication after cesarean section is considered safe for the baby during early breastfeeding, it is generally accepted that opiates should be avoided if possible. Most anesthetists now offer some form of longer-lasting local anesthesia, such as an epidural or a transverse abdominis plane block, but acupuncture can be an effective method of postcesarean pain relief after the local has worn off.
I insert needles horizontally, just under the skin, along the length and on both sides of the abdominal wound. I then use EA along the full length of the wound at frequencies of 2/100 Hz at the highest intensity acceptable without producing muscle contractions. If there is too much movement, this can cause substantial bruising. If necessary, I repeat this daily, but often only 1 or 2 applications are needed.
Six months or more after a cesarean section patients might complain of back pain or lower abdominal pain, not necessarily in the scar itself but associated on examination with acute tenderness in the scar. It is at the 6-month stage that scars have tightened and thickened, sometimes causing nerve entrapment with consequent pain. 12
I treat both the local and referred pain by needling the scar. I palpate along the length of the scar noting the most tender spots. These are sometimes at points of apparently deficient subcutaneous tissue. If there are few, I needle these points directly using EA; otherwise, I use the same technique described above for the cesarean-section wound, although muscle contraction is now acceptable. I give 20-minute sessions of stimulation and repeat at weekly intervals until the patient is pain-free.
References
Dundee JW, Sourial FBR, Ghaly RG, Bell PF. P6 acupressure reduces morning sickness. J R Soc Med. 1988:81(8):456–457.
Helmreich R, Shiao SYPK, Dune LS. Meta-analysis of acustimulation effects on nausea and vomiting in pregnant women. Explore (NY) 2006;2(5):412–421.
Forrester M. Low back pain in pregnancy. Acupunct Med. 2003;21(1–2):36–41.
Park J, Sohn Y, White AR, Lee H. The safety of acupuncture during pregnancy: A systematic review. Acupunct Med. 2014;32(3):257–266.
Cummings M. Forbidden points in pregnancy: No plausible mechanism for risk. Acupunct Med. 2011;29(2):140–142.
Betts D, Budd S. Forbidden points in pregnancy: Historical wisdom? Acupunct Med. 2011;29(2):137–139.
Hayhoe S. How do you treat back pain in your practice? Part 1. Med Acupunct. 2017;29(6):413–414.
Smith CA, Crowther CA, Grant SJ. Acupuncture for induction of labour. Cochrane Database Syst Rev. 2013;8:CD002962.
Smith CA. Acupuncture in obstetrics. In: Filshie J, White A, Cummings M, eds. Medical Acupuncture: A Western Scientific Approach, 2nd ed. Edinburgh: Elsevier; 2016:315–344.
Campbell A. Acupuncture without points. In: Filshie J, White A, Cummings M, eds. Medical Acupuncture: A Western Scientific Approach, 2nd ed. Edinburgh: Elsevier; 2016:125–132.
Smith CA, Collins CT, Crowther CA, Levett KM. Acupuncture or acupressure for pain management in labour. Cochrane Database Syst Rev. 2011;8:CD009232.
Hayhoe S. How do you deactivate painful scars in your practice? Med Acupunct. 2016;28(3):165–166.
Address correspondence to: Simon Hayhoe, MSc, MBBS, MRCA, DA
Pain Management Department
University Hospital
Turner Road
Colchester CO4 5JL
United Kingdom
E-mail:
Preeclampsia is a serious complication of pregnancy that can occur after 20 weeks of gestation. Preeclampsia is associated with new-onset proteinuria and hypertension, although other symptoms—such as thrombocytopenia, renal insufficiency, impaired liver function, and pulmonary edema—might also occur. 1 Gestational hypertension can occur without the accompanying symptoms of preeclampsia; however, it is also associated with adverse pregnancy outcomes. Obstetric practice guidelines recommend that severe blood pressure changes should be managed with the same approach as applied to women with severe preeclampsia. 1 Use of acupuncture for addressing preeclampsia has been reported in a small randomized controlled trial. 2 However, this was an intervention given when women had been hospitalized toward the end of their pregnancies. While changes in BP were reported, these were not enough to alter medical care, with no significant differences for gestational age at delivery or mode of delivery. Outcomes for medical monitoring (such as tests for proteinuria, liver enzymes, or uric-acid levels) were not reported.
In contrast, my clinical experiences of treating preeclampsia were of seeing women identified as requiring medical monitoring, but before admission to the hospital. The initial anecdotal feedback was that, within this medical monitoring, the beneficial changes in BP, proteinuria, and results of blood tests for liver enzymes and uric-acid levels enabled the women to stay in primary care without further medical intervention.
This positive feedback led to midwives in New Zealand being taught acupuncture points for addressing gestational hypertension and preeclampsia as part of my teaching for a midwifery acupuncture certificate. While in my clinical practice, additional Traditional Chinese Medicine diagnosis and individualization of treatment were used. In addition, midwives going for the midwifery acupuncture certificate were taught LI 11, ST 36, and LR 3 as a baseline point combination, with PC 6 and Yintang also suggested as possible points for women with anxiety.
In New Zealand, the majority of maternity care is through midwives acting as lead maternity carers (LMCs). As LMCs, they assume responsibility for women's maternity care and only refer women to secondary care (e.g., obstetricians, high-risk hospital clinics) as when needed.
Midwives working to obtain this maternity certificate also reported positive experiences that occurred when using acupuncture. For example:
[Acupuncture] has reduced the number of women needing medication to control blood pressure whether it be pregnancy induced or mild essential hypertension. Blood pressure in both pregnancy and labour seem less labile for these women. Proteinuria seems less common and if present, less in its severity. Observing the blood results in those women having had acupuncture every day or on alternate days shows significant biochemistry changes over a period of a week or less. Raised uric acid levels are often brought back to the normal range and [alanine transferase levels] are more likely to remain normal longer in women having regular acupuncture therapy so there is less need for intervention and the early induction of labour.”3
While the descriptive nature of individual case histories from practice lacks the capacity to link cause and effect, all good science begins with observation and description. 4 While further research on the early use of acupuncture for women with gestational hypertension and preeclampsia is required, this feedback from clinical practitioners and midwives raises interesting possibilities about the potential of acupuncture as an early intervention for this serious pregnancy complication.
References
American College of Obstetricians and Gynecologists (ACOG). ACOG Practice Bulletin No. 202 Summary: Gestational Hypertension and Preeclampsia. Obstet Gynecol. 2019;133(1):211–214.
Zeng Y, Liu B, Luo T, Chen Y, Chen G, Chen D. Effects of acupuncture on preeclampsia in Chinese women: A pilot prospective cohort study. Acupunct Med. 2016;34(2):144–148.
Betts D. The Essential Guide to Acupuncture in Pregnancy & Childbirth. Hove, England: The Journal of Chinese Medicine Publications; 2006.
Ferrigno P, Ryan JD, Ryan DJ. Writing Chinese Medicine case reports: Guidelines for the Australian Journal of Acupuncture and Chinese Medicine. Aust J Acupunct Chin Med. 1996;1:25–30.
Address correspondence to: Debra Betts, PhD, LAc
NICM Health Research Institute
Western Sydney University
Locked Bag 1797
Sydney, Penrith, New South Wales 2751
Australia
E-mail:
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Hyperemesis gravidarum is defined as unexplained intractable nausea, retching, or vomiting beginning in the first trimester, resulting in dehydration, ketonuria, and typically a weight loss of more than 5% of prepregnancy weight. Patients with hyperemesis gravidarum, rather than NVP, tend to have an earlier onset and longer duration. Excess salivation (ptyalism) may also be seen in a subset of women with hyperemesis gravidarum. Treatment includes avoidance of noxious stimuli, medications to relieve nausea and vomiting, hydration, and possibly hospitalization. Acupuncture is used as a nonpharmacologic measure. 2
Articles about using acupuncture in hyperemesis gravidarum tend to focus on Neiguan (PC 6). Carlsson et al. 3 evaluated 33 women with hyperemesis in a randomized, single-blinded crossover comparison of 2 methods of acupuncture, active (deep) PC 6 acupuncture or placebo (superficial) acupuncture. Pregnant women estimated their degree of nausea on a visual analogue scale (VAS). The women's daily number of emesis episodes were documented. Crossover analyses showed that there was a significantly faster reduction of nausea VAS, and more women who stopped vomiting after active acupuncture than after placebo acupuncture.
Shin et al. 4 reported that the degree of nausea and vomiting was statistically significant lower in patients who received acupressure to the Neiguan point acupressure in comparison with a placebo to this point and with control groups using medications. Mao and Liang 5 used acupuncture at Dazhu (BL 11), Shangjuxu (ST 37), Neiguan, and Gongsun (SP 4), and verified that acupuncture had a rapid and obvious therapeutic effect on hyperemesis gravidarum without adverse reactions.
However, according to Van den Heuvel et al., 6 in a systematic review, although there is some evidence that different acustimulation techniques reduce the combined outcome for nausea, vomiting, and ketones significantly in cases of hyperemesis gravidarum, it is too early to conclude definitely on the beneficial effects of acustimulation for the treatment of NVP and hyperemesis gravidarum, taking into account the nonsignificant results in studies with continuous outcome measures and the moderate quality of the studies, especially with regard to blinding. Future clinical trials with rigorous designs and large sample sizes should be conducted to evaluate efficacy and safety of these interventions for NVP and hyperemesis gravidarum. In this review, most studies in the trials with acupressure examined the result of the stimulation of Neiguan in studies for NVP. The studies on acupuncture for the treatment of hyperemesis gravidarum used a combination of the following five points: Zusanli (ST 36); Neiguan; Zhongwan (CV 12); Gongsun, and Sanyinjiao (SP 6).
The authors’ experience suggest that acupuncture has very good results for addressing NVP and hyperemesis gravidarum, as for other uncomfortable symptoms of pregnancy, with few and negligible side-effects, and great safety for both the mother and her fetus. As literature proposes, Neiguan is a very important acupoint for addressing nausea and vomiting, but also controls anxiety, Calms the Mind and Harmonizes the Stomach. A direct action on Stomach can be achieved by its Mu ventral point, Zhongwan, or points of the Stomach channel such as Zusanli or Fenglong (ST 40), and also points of the Spleen channel, such as Sanyinjiao, or Yinlingquan (SP 9). Although most traditional authors recommend to avoid it during pregnancy, It is our impression that Hegu (LI 4)—that Harmonizes the three Jiaos—is a good choice for special cases that are difficult to solve but must be used with care as this point favors labor. In clinical practice, the choice of those or other points, will be based on other symptoms that need to be relieved.
References
National Institute for Health and Clinical Excellence: Guidance. Antenatal care: Routine care for the healthy pregnant woman. National Collaborating Center for Women's and Children's Health (UK). London: RCOG Press; 2008.
Klauser CK, Saltzman DH. Gastrointestinal disorders in pregnancy. In: DeCherney AH, Nathan L, Laufer N, Roman AS, eds. Current Diagnosis & Treatment: Obstetrics & Gynecology. New York: McGraw-Hill; 2013.
Carlsson CP, Axemo P, Bodin A, Carstensen H, Ehrenroth B, Madegård-Lind I, Navender C. Manual acupuncture reduces hyperemesis gravidarum: A placebo-controlled, randomized, single-blind, crossover study. J Pain Symptom Manage. 2000;20(4):273–279.
Shin HS, Song YA, Seo S. Effect of Nei-Guan point (P6) acupressure on ketonuria levels, nausea and vomiting in women with hyperemesis gravidarum. J Adv Nurs. 2007;59(5):510–519.
Mao ZN, Liang CE. Observation on therapeutic effect of acupuncture on hyperemesis gravidarum [in Chinese]. Zhongguo Zhen Jiu. 2009;29(12):973–976.
Van den Heuvel E, Goossens M, Vanderhaegen H, Sun HX, Buntinx F. Effect of acustimulation on nausea and vomiting and on hyperemesis in pregnancy: A systematic review of Western and Chinese literature. BMC Complement Alternat Med. 2016;16:13.
Address correspondence to: Yolanda Maria Garcia, MD, PhD
Ambulatory of Acupuncture of the Geriatrics Discipline
Medical Clinic Department
Universidade de São Paulo Medical School
R. Teodoro Sampaio, 352–57
São Paulo–SP 05406-000
Brazil
E-mail:
Tomie Toyota de Campos, MD, PhD
Department of Prosthodontics
Center of Dental Occlusion, Orofacial Pain and Temporomandibular Dysfunction
School of Dentistry, University of São Paulo
São Paulo
Brazil
Breno Milbratz de Castro, MD
Department of Orthopedics and Traumatology
Universidade de São Paulo Medical School
São Paulo
Brazil
P
As an instructor of obstetrics and gynecology from a Traditional Chinese Medicine perspective, a clinical supervisor, and a licensed acupuncturist who specializes in the treatment of pregnancy-related care, it has come to my attention that many acupuncture practitioners are afraid of treating women during pregnancy due to the moving nature of acupuncture and high risks of miscarriage in the first trimester. This Clinical Pearl comes from lessons learned in the past when I was working at a hospital in New York City in a department of neurology and orthopedic rehabilitation.
It is wise to approach treatment with appropriate caution; when in doubt, microsystems are extremely safe and effective for most cases, including pregnant women.
Scalp acupuncture has been gaining traction since the 1950s. Many practitioners are familiar with the work of Dr. Shun Fa Jiao, PhD, MD(China), DN, DCN during the 70s, but may not be familiar with contributions to scalp acupuncture made by Dr. Ming Qing Zhu, LAc. 8 Dr. Zhu's research started in 1969 when he contributed an alternate map of scalp acupuncture. Clinically, Dr. Zhu's map is extremely effective for the treatment of PPGP. In this system, the area above the external occipital protuberance (EOP) represents the sacrum. 9 When using scalp acupuncture for sacroiliac dysfunction, the patient can be placed in a side-lying position so that the practitioner can easily access all parts of the patient's scalp.
First, I locate the primary site of pain and ask the patient to rate the intensity of pain with and without pressure that I have elicited. Then, I palpate the area above the EOP for tender points. Typically, 1 well-placed needle is enough to reduce the pain several points on the pain scale. If pain remains, a second—and even a third—scalp needle may be added to this area. For severe cases, simultaneous auricular treatment might be needed.
In minor cases, the patient's pain will resolve with 1–2 treatments. In severe cases, patients experience immediate improvement with pain levels dropping as well as increased function, but regular treatment 1–2 times per week may be needed. 10 For an extended therapeutic effect between treatments, I place auricular seeds or tacks as appropriate.
Clinical observation and research has shown that combining scalp acupuncture with auricular acupuncture is safe and can provide significant and lasting relief to patients at all stages of pregnancy.5–8,10
Illustrative Case
A 36-year-old multiparous female presented 32 weeks into her pregnancy with main complaints of anxiety and right-sided sacroiliac pain. In addition to acupuncture, she was receiving weekly midwifery care and counseling. During her initial visit, discussing her upcoming labor would bring her to tears, and she reported that her sacroiliac pain was constantly bothersome. She rated it a 4 of 10 on a pain scale. While her pain would sometimes spike to 6–7 of 10 when squatting down or picking up her 18-month-old child, it rarely got better than 4 of 10. This patient's tongue was dusky-red and pointed. Her pulse was thin, slippery, and slightly rapid.
She was positioned in a lateral recumbent position, lying on her left side with pillows used to bolster her right leg so her hips could be level and without any added stress. When she lay on the table, her pain was still 4 of 10. When I palpated the Zhu Scalp area for the sacrum, 2 tender points were identified and needled—1 just to the right of the midline and the other ∼ ¼ cun further out. The needles were angled down toward the sacrum with an even-method rotation. After I placed the 2 Zhu scalp acupuncture needles, her pain was reduced to 0 of 10. The treatment went on to include GV 20; left side: HT 7 and PC 6; right side: ST 36, LR 3, and auricular point Shen Men.
The following week, the patient reported that she was without any pain for 3 days after the acupuncture treatment. When her pain returned, it was reduced to 2 of 10, and was intermittent. The treatment was repeated with 1 additional scalp acupuncture needle added between the location of the initial 2 scalp points. In addition to acupuncture, she was sent home with vaccaria seeds on the following auricular points: Sacral Spine; Lumbago; Shen Men; Cingulate Gyrus; and Thalamus. Seeds were placed bilaterally and the patient was advised to press on the seeds throughout the day and leave them on for 4–6 days (or to remove the seeds sooner if they were bothersome). The patient's sacroiliac pain resolved completely and her mood stabilized with 2 treatments. She continued seeking weekly treatment for labor preparation but her sacral pain never returned.
References
Dall B. Sacroiliac Joint and Pregnancy: Spine-Health. 2019. Online document at: www.spine-health.com/ask-a-doctor/sacroiliac-joint-dysfunction/sacroiliac-joint-and-pregnancy. Accessed July 1, 2019.
Ceprnja D, Chipchase L, Gupta A. Prevalence of Pregnancy-Related Pelvic Girdle Pain and Associated Factors in Australia: A Cross-Sectional Study Protocol. BMJ Open. Online document at: https://bmjopen.bmj.com/content/7/11/e018334 Accessed July 1, 2019.
Filipec M, Jadanec M, Kostovic-Srzentic M, van der Vaart H, Matijevic R. Incidence, pain, and mobility assessment of pregnant women with sacroiliac dysfunction. Int J Gynaecol Obstet. 2018;142(3):283–287.
Kanakaris NK, Roberts CS, Giannoudis PV. Pregnancy-related pelvic girdle pain: An update. BMC Med. 2011;9:15.
Kvorning N, Holmberg C, Grennert L, Aberg A, Akeson J. Acupuncture relieves pelvic and low-back pain in late pregnancy. Acta Obstet Gynecol Scand. 2004;83(3):246–250.
Wedenberg K, Moen B, Norling A. A prospective randomized study comparing acupuncture with physiotherapy for low-back and pelvic pain in pregnancy. Acta Obstet Gynecol Scand. 2000;79(5):331–335.
Park J, Sohn Y, White AR, Lee H. The safety of acupuncture during pregnancy: A systematic review. Acupunct Med. 2014;32(3):257–226.
Hao JJ, Hao LL. Review of clinical applications of scalp acupuncture for paralysis: An excerpt from Chinese scalp acupuncture. Glob Adv Health Med. 2012;1(1):102–121.
Zhu M, Siu M. Color Atlas of Zhu's Scalp Acupuncture. San Jose, CA: Zhu's Neuro-Acupuncture Center, Inc.; 2007:3.
Wang SM, Dezinno P, Lin EC, et al. Auricular acupuncture as a treatment for pregnant women who have low back and posterior pelvic pain: A pilot study. Am J Obstet Gynecol. 2009;201(3):271.e1–e9.
Address correspondence to:
Tuesday Wasserman, DACM, DiplOM, LAc, CD(DONA)
Birth Center of Boulder
2800 Folssom Street
Boulder, CO 80304
E-mail:
I
Due to these risk factors, women are assessed through a routine blood test at 26–28 weeks of gestation and, in New Zealand, a hemoglobin level <100 g/L and a ferritin level <15 μmol/L require iron supplementation. Initially, this is through oral medication, but if, within several weeks, the patient does not have a hemoglobin level >100, that patient will require further assessment for an intravenous (IV) iron infusion.
In clinical practice, a Traditional Chinese Medicine (TCM) assessment for Blood Deficiency is based on presenting symptoms such as tiredness, dizziness, and/or palpitations, with observable signs, such as a pale complexion, pale lips, and a pale tongue, and usually involves a diagnosis of Qi and Blood Deficiency that can involve the Spleen, Liver or Heart. 2 Treatment outcomes are then assessed on symptom reduction. What is more, routine blood tests for anemia in pregnancy also provide an objective biomedical baseline to evaluate treatment outcomes.
In New Zealand, any pregnant woman at 26–28 weeks of gestation or later, with a hemoglobin level <100 g/L and ferritin level <15 μmol/L will receive prescribed oral iron medication. However, there are often compliance issues with women experiencing gastrointestinal (GI) side-effects and reducing or discontinuing treatment. There is a strong interest from lead maternity care midwives in any additional treatment that will improve women's hemoglobin levels and prevent referrals for IV iron infusions.
My clinical experience of treating women presenting with Blood Deficiency involves recommending moxa for home use on ST 36 (5 minutes bilaterally for 10 days). For women with very low levels of hemoglobin, BL 17 could be added to the treatment by drawing a horizontal line connecting these points across the spine and asking someone to use moxa on these points for 5 minutes every second or third day during this 10-day treatment period. Smokeless moxibustion sticks are used to increase compliance and all women are given a written sheet with instructions on using and extinguishing the moxa sticks safely. 2 The rationale for this treatment comes from the use of moxa on these points to build Blood. 3 Although women using moxa at home report reductions in their symptoms and beneficial changes in their hemoglobin and ferritin levels are noted on reassessment, it could be that women who seek acupuncture treatment might be more motivated and compliant with taking their iron supplementation and following the recommended dietary advice they receive for treating their anemia.
What is interesting is that midwives who have received a midwifery acupuncture certificate, and subsequently teach moxibustion for home use as part of their practices, report beneficial changes beyond their expectations for iron supplementation alone. This is especially relevant for women who are unable able to access acupuncture treatment due to barriers such as cost and lack of practitioners who treat pregnancy in their areas, and for women with low hemoglobin levels who experience GI symptoms with prescribed medications. Midwives report that women using moxa are able to reduce their medications or switch to lower doses or more natural forms of supplementation and still achieve the required rise in hemoglobin.
As in the case history below, midwives have also reported that this use of moxibustion on ST 36 appears to be beneficial when they are concerned that the baby is not growing as expected for gestational age. This case was reported by a midwife:
I first met Sue when she was at 36 weeks [of gestation]; she had not had much antenatal care and was planning a home birth. This was Sue's third pregnancy; her youngest child [was] 4 years old. Her haemoglobin level at 36 weeks was 103 (normal range: 100–145). Sue reported feeling tired and she looked pale; her baby felt to me to only be the size of a 32-week foetus. Blood tests at 37 weeks showed a haemoglobin of 87 and a ferritin of 7.9 (normal range: 15–150). I started her on an iron supplement (Ferrograd-Folic) and recommended the moxa treatment of BL 17 and ST 36 as a course over 10 days (smokeless moxa stick self-administered 5 minutes to ST 36 on both legs daily and administered by [her] partner to BL 17 for 5–10 minutes every 2–3 days). Sue continued to moxa for 10 days, saying she felt better each day. At 39 weeks, her blood test showed an improved haemoglobin of 102 and a ferritin of 16.5. Her baby now also felt the right size for 39 weeks. She gave birth at home at 41 weeks to a healthy baby girl weighing 3750 g. I believe the moxa treatment had a direct effect on Sue's iron levels, as an increase in haemoglobin of 15 points and ferritin of 8.6 in 3 weeks cannot be attributed to iron therapy alone.
—Kass Ozturk (midwife)
Interestingly, these beneficial effects have not been noted for women who only receive acupuncture on these points. It might be that moxa enhances the body's ability to absorb oral iron in a way that acupuncture alone does not. However. currently this is only an observation for a small number of women.
The beneficial growth of fetuses previously measuring as smaller than expected for gestational age following the self-administration of moxibustion to ST 36 is something also reported by women in my clinical practice. While midwifery palpation and ultrasound assessments of fetal growth may not be as precise as a blood test for anemia, customized assessment of birth weight and fetal growth charts are now being used in New Zealand that could provide more-accurate measurements. 4 It could be that these will provide a more-objective means to explore the use of self-administered moxibustion to encourage optimal fetal growth. A further observation from clinical practice are 2 instances in which women who were unable to give birth at home due to concerns about their platelet levels were subsequently able to plan home births as their platelets normalized following moxibustion on ST 36 and BL 17 as above.
Iron-deficiency anemia is a pregnancy-related condition that requires medical monitoring and could result in serious complications for both the mother and her baby. Clinical practice and midwifery case reports suggest early intervention with moxibustion could be a useful intervention that results in beneficial changes in hemoglobin and ferritin levels, and that this invention may also be beneficial for encouraging optimal fetal growth. Although these are only anecdotal reports, and quality research is required to provide further clarification, it is hoped that this Clinical Pearl stimulates an interest in the use of moxibustion in pregnancy. This could be especially relevant as care that can be taught to health providers for women who are unable to access private acupuncture care and for women who are reluctant to comply with oral iron supplementation due to GI side-effects.
References
Pavord S, Daru J, Prasannan N, et al. UK guidelines on the management of iron deficiency in pregnancy. Br J Haematol. 2019;October 2:e-pub ahead of print.
Betts D. The Essential Guide to Acupuncture in Pregnancy & Childbirth. Hove, England: Journal of Chinese Medicine Publications; 2006.
Deadman P, Al-Khafaji M, Baker K. A Manual of Acupuncture. London: Journal of Chinese Medicine Publications; 2001.
National Health Service. Reducing Stillbirth Through Improved Detection of Fetal Growth Restriction: A Best Practice Toolkit. November 1–2, 2014. Online document at: www.londonscn.nhs.uk/wp-content/uploads/2015/01/mat-stillbirth-fgr-122014.pdf Accessed November 1, 2019.
Address correspondence to:
Debra Betts, PhD, LAc
NICM Health Research Institute
Western Sydney University
Locked Bag 1797
Sydney, Penrith, New South Wales 2751
Australia
E-mail:
T
It is necessary not to speak of absolute infertility but various degrees of infertility or subfertility. Its importance depends mainly on the time the infertility evolves and the age of the woman but can affect either one or both partners. The most-frequent etiologies found are usually:
Male factor Ovulatory factor Endocrine, uterine, or peritoneal-tube factors.
Approximately 20% of cases do not have clear etiologies and are defined as sterility without apparent cause or of unknown origin. In Western medicine, through assisted reproductive technology (ART), it is possible to resolve most cases with hormonal therapy and surgery. ART is performed by treatments of both low and high complexity, as appropriate, including artificial insemination, in vitro fertilization (IVF), and intracytoplasmic-sperm injection. 2 However, cases without underlying physical causes—or when critical emotional factors are involved—are truly challenging and, often, repeated attempts fail.
An increasing number of studies have shown the negative influence of stress on fertility. 2 This impact, which is evident in the emotional realm, also causes biochemical and hormonal alterations that, in turn, make achieving pregnancy difficult or impossible. A study quantified the concentration of salivary α-amylase as a marker of stress in a group of women. The study reported a 29% decrease in fertility in patients who had higher levels of this enzyme. 2 The proposed mechanism for this adverse effect suggests alterations in the transport of gametes 3 or the development of an unfavorable autoimmune state for implantation. 4 Updating complementary tools that enable global approaches to treatments for patients can increase the success rates of the different treatments.5,6
Infertility in Traditional Chinese Medicine
According to the generation and control cycle and the Five Element Theory, the weakness or imbalance of a specific organ will affect the rest of the organs, showing different clinical signs. Zang organs also represent natural elements and have associated emotions (Table 1): Water and Fear correspond to the Kidney, Wood and Anger to the Liver, Fire and Joy to the Heart, Earth and obsessive thinking to the Spleen, and Metal and Sadness to the Lung. 7
Zang Organs Mainly Affected in Infertility a
Correspondences are according to the Five Elements Theory, physical, emotional, and neuropsychiatric symptoms.
Traditional Chinese Medicine (TCM) relates infertility to Kidney weakness predominantly, but, in most cases, variable combinations of organ involvement are present. When diagnosing infertility, the most important thing is to differentiate between Deficiency and Excess to treat the problem properly. 8
A study of 257 infertility cases reported in the Beijing Journal of Chinese Medicine provides an idea of the statistical incidence of each pattern type. Of these 257 cases, the following were the percentages of combined patterns 9 :
Kidney–Yang Deficit: 27.63%.
Kidney–Yang and Spleen–Yang Deficit: 12.84%.
Kidney–Yin and Liver–Yin Deficit: 11.67%.
Kidney–Yin Deficit and Empty–Heat: 5.06%.
Liver–Qi Stagnation: 7.39%.
Blood Stasis: 29.57%.
Phlegm: 3.11%.
Cold–Dampness: 2.73%.
Some of the main combinations of points used for these cases are shown in Table 2. 8
Symptoms According to TCM: Principles of Treatment and Main Acupuncture Points
TCM, Traditional Chinese Medicine.
In our country, Uruguay, Deficit has been the most frequent etiology that was seen among patients in my private consultation practice from December 2011 to December 2018.
Occasionally, however signs of Excess can be seen at both levels. On a physical level, there are severe premenstrual syndromes, clots, recurrent abortions, palpitations, and bruxism. On an emotional level, there is anxiety, insomnia, irritability, panic attacks, and amnesia. These signs indicate alterations of the Zang Liver (which mobilizes Qi and houses the Hun or Ethereal Soul) and the Heart (which mobilizes the Blood and houses the Shen or the Mind 10 ). See Table 3.
Zang Organs Occasionally Related to Infertility: Physical, Emotional, and Neuropsychiatric Signs
What is the origin of these symptoms of Excess in a condition of insufficiency? Is this Excess real?
In 30% of cases in my private consultations, the commitment of Zang Heart was in evidence.
The menstrual cycle results from the balance, opposition, and control of the Yin/Yang of the Kidney and the Heart (Water and Fire). The Qi Heart descends to the Kidney, promoting ovulation of the Yin/Yang change and the menstruation Yang/Yin. If there is a Kidney–Yin or Kidney–Yang Deficit, Kidney Water will not counteract the Fire of the Heart. The Blood–Heat harms the follicular phase, with shortening of the menstrual cycle and a thin endometrium. The imbalance by Heart–Heat, home of the Shen, will cause instability, favoring the appearance of neuropsychiatric signs, such as anxiety, amnesia, and insomnia. The underlying Deficit of Yin and Yang of KI adds to an insufficient ascent of Qi to the brain. Disharmony of HT/KI, Water/Fire, would show us a double root for neuropsychiatric signs: signs of Excess (HT) with an origin of insufficiency (KI), as in the clinical case below.
Evidence for Acupuncture
Increasingly, there are studies on the positive effects of acupuncture in the treatment of infertility, as the only treatment, or as a complement to ART treatments. The different modalities of TCM, acupuncture, electroacupuncture, moxibustion have produced specific beneficial results in various articles, as follows:
Use of alternative or complementary medicine by patients and doctors has increased markedly in recent years. Acupuncture, selenium supplementation, weight loss, and psychotherapy have produced beneficial effects. 11
Acupuncture produces good results for treating infertility in women and men. A successful treatment for restoration of fertility can be noted, improving sperm quality, ovarian function, and hormonal balance. 12
Treatment with IVF–embryo transfer (ET), acupuncture, and moxibustion affect the patient's level of estrogens on the day of induction of ovulation with human chorionic gonadotropin (hCG), improve the rate of high-quality embryos, and increase the state of endometrial blood flow and morphology for that endometrial receptivity. This combination is expected to be the auxiliary therapeutic choice for improving the outcome of IVF-ET. 13
Acupuncture was found to be beneficial for IVF outcomes in women with histories of IVF failures, and the number of acupuncture treatments is a potential influencing factor. 14
Illustrative Case
A 32-year-old woman presented with infertility. She had undergone 5 ART treatments that consisted of 3 artificial-insemination treatments and 2 IVF attempts. Her last IVF treatment had a positive ß-hCG result but culminated with a curettage at 8 weeks before there was ultrasound evidence of an embryo without cardiac activity. The patient presented with short regular cycles (25 days), reduced dark bleeding and clots, a tendency to be cold, and hair loss. Her neuropsychiatric symptoms included anxiety, insomnia, and amnesia episodes up to more than 1 day long. These episodes were preceded by great restlessness, “discomfort in the head,” and an attention deficit. Endocrinologic problems, a tumor, neurologic difficulties, and psychiatric pathologies were ruled out.
Her basal body temperature (BBT) score, in the follicular phase, reached 37.1°C (normal: <36.5°C). She had a weak pulse in her kidney and heart, a red tongue almost without flavor and an even more red tip. Systemic acupuncture was applied in weekly sessions, aimed at sedating the Heart, tonifying the Kidney, eliminating Heat, and tonifying and mobilizing her Qi and Yang. Auriculotherapy was given to Shen Men, Zero, and Brain-Master points. 15
The main combinations of acupuncture points used were:
Week 1—Calm Heart/Shen: CV 15; HT 7; and HT 3; and tonify KI: KI 3 and KI 7
Week 2—Remove Heat, tonify Yin, and mobilize Qi: LI 4; LI 11; SP 6; and LR 3
Week 3—Mobilize Qi and tonify Yang: GV 20; Ex-HN 1, and ST 36
Week 4—Optimize the menstrual cycle: LU 7; KI 6; SP 4; PC 6; Ex-CA 1; CV 4; ST 25; ST 28; BL 5; and BL 23
Weeks 5, 6 and 7—Maintain and improve menstrual cycle dynamics: SP 4; PC 6; HT 7; Ex-CA 1; HT 7; KI 7; SP 6; and LR 3.
This patient improved progressively with respect to memory and anxiety without repeated episodes of amnesia. Restful sleep was achieved, and her hair loss ceased. Her BBT temperature improved in the normal follicular phase (35.9–36.5°C) in a standard biphasic curve. Her menstrual cycle extended to 29 days, with a menstruation of red blood without clots. Her tongue changed to a standard color and coating, and her pulse indicated recovery of harmony of KI and HT. After 7 sessions, she became pregnant.
The clinical signs that show Zang Heart's imbalance in TCM are very similar to stress in Western medicine, with the already known neurohormonal impact on the reproductive cycle. In this case, acupuncture collaborated with the recovery of homeostasis and pregnancy.
References
World Health Organisation. Sexual and Reproductive Health: Multiple Definitions of Infertility. Online document at: www.who.int/reproductivehealth/topics/infertility/multiple-definitions/en/ Accessed June 27, 2019.
Lynch CD, Sundaram R, Maisog JM, Sweeney AM, Buck Louis GM. Preconception stress increases the risk of infertility: Results from a couple-based prospective cohort study—the LIFE study. Hum Reprod. 2014;29(5):1067–1075.
Schenker JG, Meirow D, Schenker E. Stress and human reproduction. Eur J Obstet Gynecol Reprod Biol. 1992;45(1):1–8.
Makrigiannakis A, Zoumakis E, Kalantaridou S, et al. Corticotropin-releasing hormone promotes blastocyst implantation and early maternal tolerance. Nat Immunol. 2001;2(11):1018–1024.
Isoyama D, Cordts EB, de Souza van Niewegen AM, de Almeida Pereira de Carvalho W, Matsumura ST, Barbosa CP. Effect of acupuncture on symptoms of anxiety in women undergoing in vitro fertilisation: A prospective randomised controlled study. Acupunct Med. 2012;30(2):85–88.
Louis GM, Lum KJ, Sundaram R, et al. Stress reduces conception probabilities across the fertile window: Evidence in support of relaxation. Fertil Steril. 2011;95(7):2184–2189.
Angela Hicks, John Hicks, Peter Mole. Five Elements Constitutional Acupuncture, 1st ed. São Paulo: Churchill Livingstone; 2007.
Maciocia G. Obstetrics and Gynecology in Chinese Medicine, 2nd ed. London: Churchill Livingstone; 2011.
Gynaecology Department of the Long Hua Hospital affiliated to the Shanghai College of Traditional Chinese Medicine. Report on the Differentiation and Treatment of 257 cases of Infertility. Zhong Yi Za Zhi. 1987;28(10):38.
Maciocia G. Intellectual and emotional faculties. In: The Psyche in Chinese Medicine: Treatment of Emotional and Mental Disharmonies with Acupuncture and Chinese Herbs. Barcelona: Churchill Livingstone; 2009.
Clark NA, Will M, Moravek MB, Fisseha S. A systematic review of the evidence for complementary and alternative medicine in infertility. Int J Gynaecol Obstet. 2013;122(3):202–206.
Zhu J, Arsovska B, Kozovska K. Acupuncture treatment for fertility. Open Access Maced J Med Sci. 2018;6(9):1685–1687.
Chen Q, Hau C. Impacts on pregnancy outcome treated with acupuncture and moxibustion in IVF-ET patients [in Chinese]. Zhongguo Zhen Jiu. 2015;35(4):313–317.
Xie ZY, Peng ZH, Yao B, et al. The effects of acupuncture on pregnancy outcomes of in vitro fertilization: A systematic review and meta-analysis. BMC Complement Alternat Med. 2019;19(1):131.
Oleson T. Auriculotherapy Manual: Chinese and Western Systems of Ear Acupuncture, 3rd ed. Lyon: Elsevier; 2003.
Address correspondence to:
Maria Virginia Rodríguez, MD
Uruguayan Association of Acupuncture
Integrative Medical Acupuncture and Fertility
8 de Octubre 2355 Ap. 1001
11200 Montevideo
Uruguay
E-mail: