11 Jul Some more words on fertility – research and Chinese Medicine understanding

WM understanding

Infertility in the western model is termed as the inability to fall pregnant after 12 months of unprotected intercourse. (McQuillan, 2003) 15% of couples face difficulties in conception (Coyle, 2005) with the diagnosis of unexplained infertility given to 20-37% of couples experiencing infertility problems. (Lessey, 2002)

Western medicine does not currently have a treatment for unexplained infertility except for the couple to undergo invitro fertilization treatment (IVF). One important point to take note of is that the diagnosis of unexplained fertility is given when the women’s hormone assays are still within the ‘normal’ range. Some women may be more or less receptive to the hormones that are available and therefore this ‘normal’ range cannot be used as a definitive. This is evident in Luteal Phase Defects where the uterine lining does not respond effectively to progesterone even though the levels are thought to be within the ‘normal’ range. (Lewis, 2003)

Stress has been recognized to be a major factor in affecting fertility with studies showing that stress can decrease chances of conception in ART by up to 93%.(Lewis3, 2003). It hinders our ability to utilize progesterone and causes the pituitary to stimulate excess secretion of prolactin which in essence, prevents fertility. (Lewis2, 2003 ) This is evident in Luteal Phase Defects where the uterine lining does not respond effectively to progesterone (Lewis2, 2003) Stress can affect the amount of hormone that is excreted as such as Luteineizing hormone which may only secreted at just enough to luteinise the follicle to make it appear that ovulation has in fact occurred whereas in reality it hasn’t. (Lyttleton, 2004)

The process leading up to conception is complicated and in a peculiar twist, the endometrium is in fact a barrier to implantation for most of the cycle, with studies showing that most successful pregnancies occur in a short span of time between day 21 and 24. (Lessey, 2002) The barrier allows for the most ideally receptive environment to be in place when the egg is to implant and acts as a barrier for the remaining duration.

High FSH levels are apparent as more FSH is needed to stimulate the follicles in order to reach ovulation.   Although FSH tests on Day 2 or 3 have been the gold standard for predicting a women’s stage of fertility, the integrins are the “best described markers of uterine receptivity and have been implicated in many aspects of reproduction , including fertilization and implantation”. (Lessey, 2002)

Age related fertility is caused by:

• Decreased monthly chance of conception
• Increased chances that a pregnancy may not go full term after implantation
• Endocrine changes such as increased FSH and decreased Inhibin-B serum levels
• Decreased amount of antral follicles in ovary. (Sterling, 2006)

Lewis believes that it is in fact the hormonal fluctuations via the dysfunctioning HPA and not necessarily the quality of the eggs that will determine a women’s capacity to ovulate. A study which transplanted the ovaries of older, anovulatory rats into younger rats who had regular hormone secretions were able to ovulate. (Lewis, undated). Medical science is investigating possibilities such as ovarian antibodies (OVAB) gonadotropin antibodies (GAB) as the cause for these disorders (Shatavi, 2006). Mullerian Inhibiting Substance(MIS) has been found to have a regulatory role in folliculogenesis and if this is interrupted could have an impact later in life causing infertility problems. (Modi, 2006)  The circadian timing system is being investigated for its cause into infertility. The circadian rhythms and recently discovered clock genes are thought to have a role in ideal reproductivity.(Boden, 2006) However, in relative terms, the field of infertility is still fairly new and as such needs a great deal more research to investigate the etiological factors of unexplained infertility.

Diagnosis and understanding according to Traditional Chinese Medicine

When diagnosing and understanding infertility, TCM places its focus on the entire process of the menstrual cycle. The follicular, oestrogenic and proliferative phase pertaining to the yin aspect and the secretory, progestogenic and luteal phase pertaining to the yang.The Chong/penetrating meridian reflects the HPO axis. The Yin (Ren/conception meridian) and Yang (governing meridian) of the endocrine system arises from the penetrating meridian, which is responsible for “follicular manifestation of growth factors and hormonal expression” (Lewis, 2003) Each aspect of these phases needs to be functioning well in order for conception to take place. Each phase follows on from the other so adequate, balanced qi, yin, yang and blood are necessary to facilitate each phase into the next. Qi needs to be smooth flowing and free from obstruction for it to guide the steps through the cycle. TCM is more concerned with the quality and ongoing nourishment of eggs, their release and journey through the fallopian tubes, and the condition of the endometrium than the more quantitative properties that is usually sought after in WM.

Maciocia states that constitutional weakness, overwork, excessive physical work, excessive sexual activity at an early age, invasion of cold and diet are the etiological factors of infertility. Differential diagnosis of infertility is made through Bian Zheng and is ultimately classified into either full or empty conditions. (Maciocia, 1998)

As well as the extraordinary meridians role in fertility, it is the Baomai that is the fundamental aspect in regards to this. The Baomai connects the heart, kidneys and uterus and it is also through this connection that the HPOA functions. The heart qi is responsible for opening and closing the uterus (the kidneys are also responsible for this especially in regard to keeping uterus close to hold a foetus) and does so through the baomai connection. (Lyttleton, 2004) The kidneys (both yin and yang aspects) are the essence of fertility. A balance of both the yin (water aspect) and yang (ministerial fire) is necessary to support and nourish conception and pregnancy.

Unexplained infertility in TCM usually falls under the category of Liver and Heart Qi Stagnation. The liver is an important organ in any gynecological issue. This is owing to its pathway through the reproductive organs and its role in keeping the smooth flow of qi throughout the body. In western medical terms it is responsible for the regulation of hormones. (Lyttleton, 2004)

TCM research

Acupuncture has been found to significantly improve the reproductive outcome of women undergoing IVF or ICSI when administered immediately before and after embryo transfer. Clinical and ongoing pregnancy rates were significantly higher in the acupuncture group (39% clinical pregnancy, 36% ongoing pregnancy) compared to the control group (26% clinical pregnancy, 22% ongoing pregnancy). This study had a further 3rd group which also received acupuncture 2 days following ET. Although this group had a higher rate of pregnancy than the control group, there was no significant difference between it and the acupuncture group who only received treatment directly before and after ET, implying that there is no benefit to having additional treatment. (Westergaard, 2006) The Westergaard study was based on protocol used in a German fertility centre which used acupuncture alongside ART and had a 42.5% success rate (pregnancy) with only 26.3% in the control group. This study did not have a third group with follow- up. (Paulus, 2002) One of the most recent of these studies took place in Australia. Women were placed into either acupuncture or sham acupuncture groups. Treatment consisted of 3 sessions. They were administered on day 9, immediately before embryo transfer (ET) and immediately after ET. Pregnancy resulted in 38% in the acupuncture group and 23% in the control group. The ongoing pregnancy rate in the acupuncture group was 28% compared to 18% in the control group, although this was not statistically significant. (Smith, 2006) Finally, another German study who used acupuncture according to TCM diagnosis and administered before and after ET and then again 3 days later. The control group received real acupuncture, but the points used were not specific in assisting implantation. The clinical pregnancy and ongoing pregnancy outcomes in the point specific acupuncture group were 33.6% and 28.4%, with outcomes in the control group achieving 15.6% and 13.8% respectively. (Dieterle, 2006)

A small study involving women who had poor follicle production despite maximum gonadotropin therapy found acupuncture to be a useful adjunt to promote follicles during IVF treatment. All of the women in the acupuncture group achieved pregnancy whereas none of the women in the control group did. Slightly more follicles and higher estradiol levels were measured in the acupuncture group, although this was not statistically significant. (P=0.08) (Emmons, 2000)

An increase in uterine blood flow is brought about by acupuncture’s sympathoinhibitory effects. (Chang, 2002) This is further suggested by a study using electro acupuncture to reduce blood flow impedence in uterine arteries of infertile women. (Stener-Victorin, 1996)

Acupuncture is thought to normalize the hypothalamic-pituitary function which further leads to proper secretion of FSH and LH and has been found to increase the diameters of ovarian follicles. This was observed in a study using electroacupuncture on Ren 3, 4, Sp 6, and an unnamed extra point over 3 days. (Yu, 1989) Chen too found that EA could regulate the HPA. (Chen, 1990)  This was further explained by the Shanghai Medical University noting that electro acupuncture could “influence some gene expression of brain, thereby normalizing normal secretion of some hormones,such as GnRH, LH and E2. The effects of EA might possess a relative specifity on acupoints”. (Chen, 1997)

Many studies on acupuncture for infertility have a strong focus on restoring ovulation, which of course is fundamental for conception. A study involving auricular acupuncture for the treatment of infertility in women with either oligoamenorrhea or luteal insufficiency observed a higher pregnancy rate compared to treatment with hormone therapy. Autonomic nervous system disorders were found to be alleviated in the acupuncture group. Side effects were only observed in the hormone group further indicating that acupuncture is a safe, effective therapy for female infertility for hormonal dysfunction. (Gerhard, 1992) A further investigation on promoting ovulation in patients with endocrine dysfunctional infertility found that a significant difference in outcomes occurred in acupuncture and control group (clomifene treatment). Acupuncture group had a 65% pregnancy rate, while the clomifene group achieved 45% pregnancy rate. (Yang, 2005)   Kidney tonics combined with acupuncture (unnamed formula) were found to be effective in the treatment of infertility due to annovulation. (This study focused on women with a high endometrial Progesterone receptor content). (Tian, 1998)

Acupuncture treatment on UB 18 (Ganshu), UB 23 (Shenshu), Ren 4 (Guanyuan), Ren 3 (Zhongji) and Sp 6 (Sanyinjiao) (average of 30 treatments) with the aim to strengthen the liver and kidney and regulate the Chong and Ren meridians to be able to nourish the uterus and restore function of the HPA and ultimately to restore ovulation.   The results of this study showed that acupuncture may regulate FSH, LH and E2   in the generative and physiologic axis in women and furthermore raise progesterone levels. (Mo, 1993)

In an attempt to minimize the amount of pharmaceuticals administered during the IVF procedure, acupuncture was used successfully to replace human chorionic gonadotropin (HCG). (Xuefen, 1997)

A combined approach using external Chinese herbs on Ren 8 (Shenque) and salpingostomy for the treatment of obstructed fallopian tubes found a total effective rate of 82.2% compared to the control group (salpingostomy only) 70%. (Huang, 2005)

WM Research

“dietary and endocrine manipulations can also slow the pace of ovarian aging” Godsen & Finch cited by Lewis, undated) It was found that by feeding a low calorie diet to rodents, the disappearance of ovarian follicles was slowed down. (Lewis)