Fertility, Endometriosis/Period pain and Acupuncture

Historical perspective
Traditional Chinese medicine (TCM) has a long history related to infertility, as far back as 200 A.D herbs were documented as being used to treat health issues we would now call infertility and miscarriage. The length of time a traditional medicine has been used does not imply evidence of effectiveness, it does show our current issues are not a new event, although the factors leading to difficulties may have changed as lifestyles changed.

Traditional Chinese views are that infertility tends to arise from one or more of three prominent causes:

1. A “deficiency” syndrome prevents the hormonal system from properly influencing the sexual and reproductive functions.
2. A “stagnancy” syndrome prevents the sexual and reproductive organs from functioning despite normal hormone levels and normal ability to respond to hormones.
3. A “heat” syndrome, which causes the affected organs to function abnormally. Heat syndromes may be associated with an infection or inflammatory process. (Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine).

TCM diagnosis is based on observation of the tongue, palpation of the pulse, and questions regarding general health and lifestyle. The Basal Body Temperature chart (BBT) is used to aid diagnosis, as are the signs and symptoms of western medically recognised ailments such as endometriosis, and tests and investigations.

Please note your western medical diagnosis, be that endometriosis, pcos, low ovarian reserve, implantation failure, etc is not what will be treated. Chinese medicine is a complete health system using its own diagnostic methods to conclude a Chinese Medical diagnosis, for example qi and xue xu. It is this diagnosis based on your signs and symptoms which will be treated and adjusted as your signs and symptoms change.

Acupuncture had been considered a worthy adjunct by many western fertility specialists. In a normal cycle a woman will produce 1 occasionally 2 mature eggs, in IVF increased hormone levels mean many more (preferably 6-12) are matured. This increase is demanding on the body as demonstrated by fatigue, a common complaint. By working with your Qi and Blood (Chinese medicine terms) acupuncture may help deliver the required energy to feed those hungry ovaries.
It is preferable to begin acupuncture at least 3 months before your IVF cycle, the reason for this is
1.To build your reserves ready to sustain the demands of increase egg production.
2. Fertility isn’t just about the eggs, underlying conditions such as stagnation of blood or damp which may be associated with western medical terms such as PCOS and endometriosis have a negative impact. Calming those underlying conditions will prepare your body to be able to conceive.
3. Follicles begin their development 3 months before ovulation. In undertaking Fertility preparation, you will be encouraged to make healthy lifestyle changes, mentally and physically and hence your natural fertility is enhanced.

If your IVF is about to begin acupuncture support may still be of benefit, although I would strongly advise you try to make time for 1-2 sessions while stimulating and continue the support post transfer.

Short duration treatment does appear to reduce the stress associated with transfer and IVF(Shen et al 2014), but to limit the effect of acupuncture to just stress relief when greater effect is possible seems incongruous. Sutton et al 2014 showed greater levels of stress relief when acupuncture was conducted for more than a month compared to just on transfer day and were highest when acupuncture was administered at reproductive based acupuncture clinics compared to general acupuncture clinics.

The hormones involved in stress appear to effect more than just your mood, many responses within the body have been observed, including within follicles themselves.

Endometriosis can cause intensely painful menstruation or be almost symptomless. Endometriosis’s effect on IVF cycles has been debated but now it is generally accepted it lowers clinical pregnancy rates in IVF. Yang Xu’s 2017 systematic review of acupuncture for endometriosis related pain found although there are few randomised, blinded clinical trials the current literature suggests that acupuncture reduces pain and serum CA-125 levels. J Zhang’s 2020 systematic review found acupuncture significantly increased pregnancy and ovulation rates and reduced miscarriage. (Effectiveness of different acupuncture for infertility: Overview of systematic reviews and network meta- analysis, J Zhang, Y He,Y Lui, X Huang, H Yu, 2020.)

Triciana Mira’s 2018 systematic review and meta- analysis of complementary treatments for women with symptomatic endometriosis found…’Numerous complementary treatments have been used to alleviate the symptoms of endometriosis, but only acupuncture has demonstrated a significant improvement in outcomes.’. (Systematic review and meta-analysis of complementary treatments for women with symptomatic endometriosis Ticana A.A Mira, Marianna M Buen, Murilo G Borges Daniela A Yela, Cristina L Benetti-Pinto, 2018)

Kong et al 2014 showed complementary therapies including acupuncture and herbs can assist by shrinking the lesions, suppressing the symptoms, and decreasing the recurrence rate. This alone or with western medical treatment can tip the balance enough to allow natural fertility or IVF to work.

Australian Mike Amour, has been researching Dysmenorrhea (period pain), endometriosis and acupuncture at the University of Western Sydney. His research is quoted on many endometriosis advice pages, and he is on many advisory boards and research committees looking at endometriosis care.

Chinese medicine has never diagnosed endometriosis per se, but Chinese medicine did recognise disease patterns associated with menstrual issues such as painful, or heavy periods, scanty or stop start periods, and digestive disorders like constipation, diarrhoea, and lower abdominal pain. In some of these patients endometriosis would be the underlying cause of symptoms. By treating these ‘symptomatic diagnoses’ the underlying causative agent (endo) was addressed without being definitively diagnosed via laparoscopy.

Women suffering with polycystic ovarian syndrome are often offered ovulation induction with Clomid or Letrazole, or IVF. After discussing many aspects of your general health, including signs and symptoms of the medical condition called ‘PCOS’, a Chinese diagnosis is made and treatment is designed towards this TCM diagnosis, not your western labelled disease of PCOS. Chinese herbs may be advised. We aim to improve your health, and the type of changes you can see are increased energy, decreased cravings for sugar, and improved menstrual regularity as shown in Reid, K 2015, (https://doi.org/10.1016/j.ctim.2014.12.004).
Research has shown combining acupuncture, herbs and Clomid gives PCOS sufferers better results than just with acupuncture or Clomid alone. Improving pregnancy rates, miscarriage rates, cervical mucus, and the thickness and maturation of the uterine lining. Jiang D, Zhang Y, Wu X, Wu S, 2015 (https://europepmc.org/abstract/med/25854013).

A systematic review published in 2019 showed Chinese medicine as a non pharmacological intervention for PCOS added to western ovulation induction treatments improved fertility, and acupuncture showed some evidence of improved glycaemic outcomes. (quality of evidence scored differently on different scales, and more research larger trials is suggested). Human Reproduction Update, pp. 1–14, 2019 doi:10.1093/humupd/dmy045

1% of couples trying to conceive are affected by recurrent miscarriage, the psychological damage this condition causes is substantial, a 1/3 of them will be clinical depressed and 1 in 5 have damaging levels of anxiety. Acupuncture is known to address stress and its damaging effects. Emotional support during early pregnancy, although not understood, is known to reduce miscarriage. This effect is put to go use in IVF clinics where scans and repeat blood tests are used to alleviate stress.

Chromosomal issues account for some cases, but metabolic issues such as thyroid disorders, hyperinsulinaemia, antiphospholipid syndrome and coagulation defects are also implicated. I do not treat these conditions themselves but can assist you in approaching your western medical team to have them investigated.

In a 2016 Cochrane review into Chinese herbal medicine treatment the authors conclusions were

Author’s conclusions:
We found limited evidence (from nine studies with small sample sizes and unclear risk of bias) to assess the effectiveness of Chinese herbal medicines for treating unexplained recurrent miscarriage; no data were available to assess the safety of the intervention for the mother or her baby. There were no data relating to any of this review’s secondary outcomes. From the limited data we found, a combination of Chinese herbal medicines and other pharmaceuticals (mainly Western medicines) may be more effective than Western medicines alone in terms of the rate of continuing pregnancy and the rate of live births. However, the methodological quality of the included studies was generally poor.

A comparison of Chinese herbal medicines alone versus placebo or no treatment (including bed rest) was not possible as no relevant trials were identified.

More high-quality studies are needed to further evaluate the effectiveness and safety of Chinese herbal medicines for unexplained recurrent miscarriage. In addition to assessing the effect of Chinese herbal medicines on pregnancy rate and the rate of live births, future studies should also consider safety issues (adverse effects and toxicity for the mother and her baby) as well as the secondary outcomes listed in this review. This review would provide more valuable information if the included studies could overcome the problems in their designs, such as lacking of qualified placebo-controlled trials, applying adequate randomisation methods and avoiding potential bias.

Li L, Dou L, Leung P, Chung T, Wang C, 2016. https://www.cochrane.org/CD010568/PREG_chinese-herbal-medicines-unexplained-recurrent-miscarriage. If you wish to discuss supporting early pregnancy, and the steps taken to ensure herbal safety at this clinic please call 0422 044 259.

This is infrequent, irregular or absent cycles, possibly following medium to long term contraceptive pill use or because of underlying conditions such as polycystic ovarian disease or premature ovarian failure (premature menopause).
These underlying conditions are western medical diagnosis, and as explained Chinese medicine does not treat your western diagnosis. A complete assessment will be made and treatment will be aimed at your TCM diagnosis, with signs and symptoms constantly being reassessed including frequency and character of menses.

Chinese medicine can assist in improving the regularity of menstrual cycles as shown in Reid, K (2015) https://doi.org/10.1016/j.ctim.2014.12.004

Premature menopause brings uncomfortable menopause symptoms, but for fertility can be devastating. High FSH levels can mean clinics are unable to stimulate the ovaries. In a small pilot study in 2014 acupuncture treatment indicated it may be able decrease FSH. Yingru Chen,1 Yigong Fang,1 Jinsheng Yang,1 Fei Wang,2 Yingying Wang,1 and Li Yang1, 2014. http://dx.doi.org/10.1155/2014/718675

Improving hormone levels can assist, supporting this improvement by addressing diet, some supplement use and lifestyle changes is important, as is reducing the detrimental effect of stress. The quality of the eggs is not the only factor in fertility success, stronger sperm quality can assist the egg.

Although a little different to Chinese herbal medicine Korean herbal medicine  has been studied in a small study for diminished ovarian reserve.

Objective The purpose of the present study is to retrospectively evaluate the effect of traditional Korean medicine (TKM) on ovarian reserve by measuring serum anti-Müllerian hormone (AMH) levels in patients with diminished ovarian reserve (DOR). Study design We performed a retrospective chart review of patients with DOR who had received TKM for at least 2 months and had undergone serum AMH tests before and after TKM treatment. A total of 22 patients with DOR were included in the study. Results There were no significant differences in AMH levels before and after TKM in all patients (n=22,p=0.237). However, when the study population was divided into two age groups (=38 years (n=10)) to determine whether there was a age-related difference in the effect of TKM with DOR, a significant increase in AMH levels before and after TKM was observed in the age <38 (p<0.05). Conclusions TKM may provide an effective option for patients aged <38 years with DOR, but it should be interpreted cautiously as more rigorous research is needed. Further studies in a larger population are needed to confirm these results and to evaluate the effects of improved ovarian reserve on fertility outcomes following TKM in patients with DOR. Jo J1, Kang MJ2, Lee JM3, Kim H4, Jerng UM5.doi: 10.1016/j.ctim.2015.12.005. Epub 2015 Dec 18.

Zhou 2016 showed in patients undergoing IVF with decline in ovarian reserve that acupuncture improved number of eggs, fertilisation, nd outcomes.

This section is under review.

Having a diagnosis of low ovarian reserve (ovaries equivalent to an older woman) or responding poorly to IVF medications is very distressing and makes IVF success harder. Although no large studies or systematic reviews have been done small studies of acupuncture before and during IVF have shown acupuncture may assist to improved oestrogen levels, have more eggs retrieved, and  fertilised, more quality embryos, a higher implantation and clinical pregnancy rate and less cancelled cycles. ( Zhou 2016).
Methods of supporting your reserve will be discussed such as supplements, diet, exercise and stress reduction.

Fertility requires healthy sperm as much as healthy ova. 50% of the genetic make of the embryo comes from the man.  Women are born with all the eggs they will ever produce, men are luck enough to have the cells from which billions of sperm can be made. Sperm production takes 3 months, although the final stages occur quite soon before they are ready so even short term assistance can see improvements occur.

A 2016 Meta Analysis by K Reid found  Chinese herbal medicine improved pregnancy rates 2 fold within 3 to 6 months of treatment compared to western medical drug therapy (Complement Ther Med. 2015 Feb;23(1):116-28. doi: 10.1016/j.ctim.2014.12.004. Epub 2015 Jan 3.Chinese herbal medicine for female infertility: an updated meta-analysis). Viable pregnancies were encouraged via improves ovulation rates, cervical mucus, improved biphasic appearance in basal body temperature charts, and appropriately thickened endometrial linings. Not all women wish to take Chinese herbs, but for those who do they can be incorporated into treatment. Please feel free to ask questions about the steps taken at this clinic to ensure the safety of the herbs used.