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July 2001; Volume 4; 80-83
By Judith Balk, MD, FACOG
A common condition seen in medical practice, infertility is described in Western medicine as the inability of couples of reproductive age to establish a pregnancy by having sexual intercourse within a certain period of time, usually one year.1 Causes include anovulation, pelvic factors such as adhesions and tubal occlusion, cervical factors, and male factors such as oligozoospermia, low sperm motility, or low volume of semen. In Western medicine, treatment is aimed at correcting the etiological factor after ruling out other causes of infertility.
Etiology in Traditional Chinese Medicine
According to traditional Chinese medicine (TCM), the etiology of infertility also may be multifactorial, and may include constitutional weakness, overwork, excessive physical work, excessive sexual activity at an early age, invasion of cold, and diet.2 TCM treatment attempts to correct the underlying problem through use of herbal preparations and acupuncture. Prescriptions date back hundreds of years, and as early as 259 AD, acupuncture formulae were given for infertility. Prescriptions varied based on the presence or absence of clinical factors such as abdominal pain, white vaginal discharge, and stasis of blood.2
In TCM, male infertility is thought to be caused by kidney deficiency. Treatment is aimed at promoting the circulation of Qi and blood and at regulating yin and yang. Additional aims are to promote the generation of vital essence and to enrich the source of vital energy and the essence of kidney.3
Mechanism of Action
The mechanisms of action by which acupuncture may treat infertility have not been elucidated. One possible mechanism is via hormonal regulation, with acupuncture regulating a dysfunctional hypothalamic-pituitary axis. Another mechanism might be improvement in uterine blood flow, which increases the receptivity of the endometrium to a fertilized egg.
A MEDLINE search of the terms acupuncture and acupuncture therapy plus infertility revealed 10 journal articles since 1966. Seven of these are in English. Using the Cochrane Controlled Trials Register, two new clinical trials were obtained using the same search terms. Although five trials had control groups, only two of seven trials were randomized. Other studies are case series or a case report. Unfortunately, the lack of randomization limits the utility of the rest of these studies. One controlled trial included both animals and humans.
One animal study was performed in China.4 The article was difficult to read and interpret, in part because of a language barrier and in part because of the study’s complexity. Briefly, half of the rats underwent ovariectomy; then, half of the ovariectomized rats and half of the intact rats received electroacupuncture. At the completion of the study, the animals were sacrificed and studied.
The authors found that acupuncture in the ovariectomized rats induced maturation of the vaginal cells and increased blood concentrations of estradiol. Acupuncture also enlarged the adrenals and increased concentrations of corticosterone and beta-endorphin and decreased gonadotropin-releasing hormone (GnRH) and luteinizing hormone (LH). The authors conclude that the effects of acupuncture may be to "promote the function of hypothalamic-pituitary-adrenal axis, increasing the synthesis and secretion of adrenal steroid hormones, the androgen of which then be (SIC) transformed into estrogen in other tissues and thereby reset the negative feedback of estrogen to hypothalamic-pituitary-ovarian axis." If correct, this hypothesis would result in an estrogenic stimulus.
Human Female Studies—Treatment
Infertile patients may seek assisted reproductive techniques such as in vitro fertilization (IVF). Successful IVF depends on adequate endometrial receptivity. Acupuncture has been demonstrated to improve uterine blood flow impedance, which is a measurement of blood flow to the uterus. It has been considered valuable in assessing endometrial receptivity.5 Ten subjects with a high pulsatility index, a measurement made using Doppler transvaginal ultrasound, were treated with twice weekly acupuncture for the month prior to embryo transfer. A high pulsatility index is evidence of decreased uterine artery blood flow. Pulsatility index decreased both at the time of the embryo transfer and again at follow-up approximately two weeks later. The authors suggest that the effects arise from a central inhibition of the sympathetic activity.
Acupuncture also has been studied as analgesia during infertility treatment. A randomized controlled trial compared acupuncture to alfentanil as anesthesia for oocyte aspiration during IVF.6 One hundred fifty women participated in this study. The acupuncture group experienced discomfort for a longer period of time during oocyte aspiration, but no differences between the groups were noted by visual analog scale, adequacy of anesthesia during aspiration, abdominal pain suffered, or degree of nausea. Surprisingly, the acupuncture group had a statistically significantly higher implantation rate, pregnancy rate, and take home baby rate per embryo transfer. Compared with the alfentanil group, the electroacupuncture group’s implantation rate was 27.2% vs. 16.3%; pregnancy rate was 45.9% vs. 28.3%; and take home baby rate was 41% vs. 19.4% per embryo transfer. The same authors are conducting a larger study to corroborate these findings.
A large fibroid may cause infertility. One case report presented a patient with a 13 x 8 x 10 cm fibroid uterus who had secondary infertility, unresponsive to "repeated" cycles of IVF.7 The exact number of IVF cycles was not reported. This patient underwent acupuncture treatment and her uterus decreased to 7 x 8 x 8 cm, after which she had successful IVF and delivered healthy twins.
The studies cited above all used body points, but auricular (or ear) acupuncture also has been used to treat female infertility.8 Forty-five infertile women with either oligomenorrhea or luteal insufficiency were treated with auricular acupuncture. Results of treatment were then compared with matched subjects who were treated with hormones. Pregnancy rate was similar for both groups, whereas side effects were observed only in the hormone group. However, the groups were not equal even though they were matched on several criteria. The authors conclude that auricular acupuncture seems to offer a valuable alternative therapy for female infertility from hormone disorders. However, lack of randomization and differences between the groups limit the ability to make this conclusion.
Human Female Studies—Hormone Levels
Chinese investigators studied 10 anovulatory women and five women with normal menstrual cycles.4 Subjects were treated with electroacupuncture for 30 min/d for three days per month for 13 cycles. Changes in blood hormone concentration were measured. Beta-endorphin, LH, and follicle-stimulating (FSH) normalized in those who ovulated but did not change in those who did not ovulate. However, the determination of ovulation was not described, and other important methodological details are missing.
Another Chinese study was equally difficult to interpret.9 Thirty-four subjects with amenorrhea and dysfunctional uterine bleeding received acupuncture three times per week for three months. The terms that the authors use are unclear. Criteria for the efficacy of therapy for inducing ovulation were defined as markedly effective, effective, or ineffective, based on ultrasound, basal body temperature, and presence or absence of menstruation. Thirty-five percent, 48%, and 18% were markedly effective, effective, and ineffective, respectively. An endocrine profile was performed in 20 subjects before and after treatment. FSH, LH, and estradiol normalized compared to pre-acupuncture values. However, the time during the menstrual cycle at which the blood was drawn was not stated; different timing could greatly skew these results.
Human Male Studies
Four studies report on acupuncture as treatment for male infertility. One report is a prospective, non-randomized, controlled trial.10 Men were "subfertile," defined by lack of conception and abnormal semen analysis. Criteria for defining abnormal semen analysis are not stated. Sixteen subfertile men were treated with acupuncture twice per week for one month and were compared with 16 subfertile men who received no acupuncture. Blinded observers read the semen analyses. At baseline, both groups had similar results. No changes occurred in the untreated group at follow-up, whereas the treated group improved in three aspects of the semen analysis: percentage of sperm viability, total number of motile sperm, and total functional sperm fraction. Four spontaneous pregnancies occurred following the acupuncture treatment, but how soon after the treatment the pregnancies occurred is not stated.
A larger Chinese study was a randomized, controlled trial of 297 men with infertility.3 In this study, patients were randomized to receive various combinations of acupuncture, point-injection of essence of pilose antler, and oral administration of Chinese materia medica, which is an herbal prescription consisting of eight different compounds; thus, five different groups of subjects were formed. The materia medica preparation was individualized based on symptoms. All patients received acupuncture as part of the treatment. Baseline and follow-up semen analyses were performed on all subjects.
Of the 297 cases, roughly half were "cured," meaning pregnancy occurred. Approximately one quarter normalized their semen analysis, and the rest continued to have abnormal semen analyses. Of the five groups, treatment with all three modalities yielded the best results and oral drugs plus injection yielded the worst results. Those men with aspermia or very low sperm count (£ 1 million) had fewer cured cases than those with higher sperm counts. Also, the therapeutic effects were better in younger compared to older patients. Statistical analysis, adequate definitions of therapeutic effect, and method of randomization are not presented in this article. Obviously, the modality of injecting drug into acupuncture points is not commonly used in Western countries.
Lastly, a German abstract describes an attempt to treat subfertility in 28 males, noting that the experiences in veterinary medicine encourage them to attempt this type of therapy.11 Total count, concentration, and motility all improved following acupuncture for three weeks. Again, abstracts do not give sufficient information to make firm conclusions.
A small number of studies have been conducted to investigate the effect of acupuncture on both male and female infertility. Lack of rigorous design, inadequate definitions, and language barriers all make the present data unconvincing.
Although many of the above studies indicate the potential effectiveness of acupuncture on infertility, each study is limited by lack of rigorous study methods. In the absence of rigorous methodology, the data are not persuasive either in favor of or against acupuncture in the treatment of infertility. More research is absolutely necessary to make a firm conclusion about effectiveness.
1. Mishell D, et al. Comprehensive Gynecology. 3rd ed. St. Louis: Mosby; 1997.
2. Macioca G. Obstetrics & Gynecology in Chinese Medicine. New York: Churchill Livingstone; 1998:959.
3. Zheng Z. Analysis on the therapeutic effect of combined use of acupuncture and medication in 297 cases of male sterility. J Trad Chin Med 1997;17:190-193.
4. Chen BY. Acupuncture normalizes dysfunction of hypothalamic-pituitary-ovarian axis. Acupunct Electrother Res 1997;22:97-108.
5. Stener-Victorin E, et al. Reduction of blood flow impedance in the uterine arteries of infertile women with electro-acupuncture. Hum Reprod 1996;11:1314-1317.
6. Stener-Victorin E, et al. A prospective randomized study of electro-acupuncture versus alfentanil as anaesthesia during oocyte aspiration in in-vitro fertilization. Hum Reprod 1999;14:2480-2484.
7. Sternfeld M, et al. The effect of acupuncture on functional and anatomic uterine disturbances: Case report-secondary infertility and myomas. Am J Acupuncture 1993;21:5-7.
8. Gerhard I, Postneek F. Auricular acupuncture in the treatment of female infertility. Gynecol Endocrinol 1992;6:171-181.
9. Mo X, et al. Clinical studies on the mechanism for acupuncture stimulation of ovulation. J Trad Chin Med 1993;13:115-119.
10. Siterman S, et al. Effect of acupuncture on sperm parameters of males suffering from subfertility related to low sperm quality. Arch Androl 1997;39:155-161.
11. Fischl F, et al. Modification of semen quality by acupuncture in subfertile males [in German]. Geburtshilfe Frauenheilkd 1984;44:510-512.