By Elad Schiff, MD
Dr. Schiff is a Fellow in the Program in Integrative Medicine, University of Arizona, in Tucson.
Infertility is defined as the inability to achieve pregnancy after one year of unprotected intercourse. An estimated 15% of couples meet this criterion and are considered infertile. Half of these couples will have a component of male factor infertility and almost 30% of infertility will be due solely to male factors.1
Male conditions that affect fertility are still under-diagnosed and under-treated, as compared to female factor infertility. A complete evaluation is mandated for infertile men, which includes relevant medical history, physical exam, and laboratory and imaging studies.2 In general, causes of infertility in men can be explained by deficiencies in ejaculate volume, sperm concentration (e.g., oligospermia, azoospermia), sperm motility, or sperm morphology. Male infertility can be due to anatomical abnormalities, endocrinopathies, or systemic disease. However, the clinician managing patients with male infertility often is frustrated by the limited therapeutic options available, especially since in 40% of patients no cause for the infertility can be found.3
After identifying abnormal parameters, the care of a subfertile male may depend on the desires of the affected couple, available resources, local referral patterns, and the treatment style of the involved physician. Various treatments exist for the infertile male, ranging from optimizing the current semen parameters with medical therapy, to minor surgical procedures, and finally to complex sperm retrieval and assisted reproduction techniques.
Approximately one-third of infertile males seek non-conventional therapies for their ailment.4 In the complementary and alternative medicine (CAM) setting, patients may be offered a variety of interventions such as dietary manipulation, supplements, herbs, mind-body practices, or specific CAM modalities.5,6 Acupuncture is one of the most studied CAM modalities for male infertility. This article will review and analyze the available literature on acupuncture for male infertility.
TCM for Male Infertility
In traditional Chinese medicine (TCM), symptoms are a manifestation of an underlying qi (or chi) imbalance. There are six major patterns of qi (vital energy) disharmony that may manifest with male infertility.7 The two most commonly involved organs in male infertility according to TCM are the kidneys and liver. The kidneys store essence qi, which roughly corresponds to the Western concept of male reproductive cells, while the liver stores blood and regulates the flow of qi, which are both fundamental for fertility.
Traditionally, patients are categorized into their pattern of qi disharmony and treated accordingly with acupuncture and/or herbs. In addition, patients may receive lifestyle recommendations with regard to frequency of sexual activity, diet, exercise, and meditative practices as stress reduction techniques.
Within the paradigm of acupuncture, several approaches have evolved. Formulations of acupoints that have been empirically and traditionally associated with fertility-boosting effects may be used in protocols for infertility treatments. These protocol-based acupuncture treatments do not attempt to address the underlying qi disharmony. More recently, following the development of French auricular acupuncture therapy and its endorsement in China, several protocols also combine auriculotherapy.
Zongchang published a case series of 297 infertile males treated with various combinations of acupuncture, acupuncture point injections with Pilose Antler (a powder from the hairy, non-ossific, young horn of a stag), and Chinese herbs.8 Interventions were protocolized for acupuncture and point injections. Herbs were provided based on a standard formula on top of which other herbs were added according to specific TCM patterns of disharmony. Patient population was heterogeneous for age, underlying infertility etiology, sperm motility indices, and sperm count. Sperm morphology was not evaluated. Courses of acupuncture and point injection treatments were variable in length and were not well characterized in the article. Within the time period of eight treatment courses, approximately 50% of patients achieved pregnancy, 27% achieved normal sperm count and motility, 18% improved sperm count but not sperm motility, and 7% had no change in the above outcomes. Highest rates of improvement were noticed in the group that received a combination of all three interventions—herbs, acupuncture, and point injections.
This study exemplifies the common practice of TCM for male infertility in China, in that several interventions often are used. Although this article documents very high success rates, the methods used to report patient characteristics, treatments applied, and outcome measures are not rigorous, which makes it difficult to draw conclusions.
Controlled Clinical Trials
In a single-blind controlled trial, 19 patients (24-42 years of age) with semen abnormalities in concentration, morphology, and/or motility, were randomized into two groups.9 The study group received protocolized acupuncture plus moxa (warming Artemisia vulgaris wool over acupuncture points), while the control group was needled in acupuncture points not known to have any effect on infertility. Treatment was given twice weekly for 10 weeks. Semen analyses were performed before and after the treatment course. Patients in the study group showed a significant increase in the percentage of normal-form sperm compared to the control group. However, there were no significant differences between the two groups in sperm volume, concentration, or motility. Pregnancy outcomes were not mentioned in the article. This study suggests that acupuncture can improve sperm morphology, but not sperm activity or count. Although important, sperm morphology is just one of the variables necessary for fertility. Therefore, one cannot project from this study how acupuncture may affect the single most important outcome for infertile males—successful fertilization of an egg.
Siterman and colleagues conducted two randomized trials to assess the effect of acupuncture on the sperm quality of males experiencing subfertility related to sperm impairment.
In the first study, 16 males (average age 35 ± 5 years) with subfertility associated with low sperm activity received acupuncture treatments twice weekly for five weeks.10 A group of acupuncture points with effects on fertility was predefined for this study. From this group of points, the therapist selected specific points for individual patients according to their pattern of disharmony. Semen was assessed one month pre- and post-treatment in the acupuncture and the control group. Sixteen untreated subfertile males, matched with the experimental group for semen characteristics, served as a control group. The fertility index, which serves as a validated predictor of fertility, increased significantly in the acupuncture group following improvement in total functional sperm fraction, percentage of viability, total motile spermatozoa per ejaculate, and integrity of the axonema (structure of the sperm tail). Four (25%) spontaneous pregnancies were achieved in the acupuncture group.
In their second randomized trial, Siterman et al evaluated the effect of acupuncture treatment on sperm density. Semen samples of 20 males with previously diagnosed azoospermia (the complete absence of sperm) were observed before and after acupuncture treatment using routine light microscope and special micro-scanning electron microscope examinations. These males had failed to achieve natural fertilization for an average period of 9 ± 4 years and none had undergone any treatment for at least one year prior to acupuncture. Age in both acupuncture and control group averaged 39 ± 7 years. Following microscopy studies and endocrinologic evaluation, participants were categorized into three subgroups:
1. Patients (n = 6) with high follicle-stimulating hormone (FSH) and/or leutinizing hormone (LH) levels without any signs of genital tract inflammation, were defined as suffering from spermatogenic failure.
2. Patients (n = 9) with normal basal blood FSH and LH levels, who exhibited signs of genital tract infection according to the laboratory criteria, were defined as suffering from inflammation of the genital tract.
3. Patients (n = 5) who exhibited high FSH and/or LH levels as well as inflammation of the genital tract, were defined as a combined subgroup of spermatogenic failure and genital tract inflammation.
Twenty males receiving no treatment with a matching andrological profile served as the control group. Acupuncture treatment was individualized according to the TCM pattern of disharmony, and was administered twice weekly for five weeks. Following treatment, 13 males exhibited a considerable improvement in sperm density. Even the three males with the most severe reduction in sperm count exhibited a marked but non-significant improvement in their sperm count (average 0.7 ± 1.1 × 106 spermatozoa per ejaculate before treatment vs. 4.3 ± 3.2 × 106 spermatozoa per ejaculate after treatment). No effect was observed in the spermatogenic failure patients (subgroup 1). Patients suffering from genital tract inflammation responded well to acupuncture treatment although levels of white blood cells and bacteria did not change following acupuncture treatment. Also noteworthy is that no changes in basal hormonal blood levels were observed in any of the participants of the experimental group. None of the untreated controls exhibited any substantial changes in sperm density. Only two of the 20 treated patients underwent in vitro fertilization with intracytoplasmic sperm injection (ICSI) following the acupuncture procedure. Pregnancies were achieved in both cases.
These studies are important in that patients were well characterized for their sperm abnormality, and that research methodology and outcome measures were adequate. Moreover, these studies, especially the latter, help identify infertility characteristics that are more amenable to acupuncture therapy. In summary, both sperm activity and sperm density were positively affected by acupuncture treatment.
A study by Paulus and colleagues assessed the influence of acupuncture on pregnancy rates in patients who undergo assisted reproduction therapy.11 This study did not evaluate acupuncture’s effectiveness on improving semen parameters but rather if acupuncture can improve pregnancy rates after ICSI. The severe male subfertility group in this study was randomized to either acupuncture plus ICSI (n = 33) or ICSI only (n = 26). Each female in the experimental group received a protocol-based body and ear acupuncture treatment. Acupuncture was administered 25 minutes before and after embryo transfer. Pregnancy rates for the acupuncture group were considerably higher than for the control group (42.5% vs. 26.3%; P = 0.03).
A small case series echoes Paulus’ results and describes better outcomes for ICSI with acupuncture in terms of follicle yield and pregnancy rates.12
The controlled trial and case series are important, since with a brief, safe, and inexpensive intervention (acupuncture), it appears one can optimize the main outcome for a complex and highly expensive procedure.
Mechanism of Action
The possible mechanisms by which acupuncture improves sperm morphology and activity were not directly studied. However, several mechanisms were suggested in the above articles.
Acupuncture point stimulation may facilitate, through neuronally mediated mechanisms, vasodilatation to testicular and epididymeal structures. Vasodilation to these organs may in turn reduce oxidative stress, which contributes to subfertility.9
Acupuncture may also exert its effect via optimization of endocrine function. In at least one study, acupuncture was shown to cause a significant increase in beta-endorphin.13 Beta-endorphins in turn affect GnRH secretion, which regulates the reproductive organs. In addition, acupuncture has been shown to normalize the hypothalamus-pituitary-reproductive organ axis.14 These hormonal effects may create a more favorable environment for reproductive function.
Moreover, emotional stress is an acknowledged factor that decreases fertility rates.15 Acupuncture can reduce anxiety and stress both through specific, non-specific, and placebo effects, thereby diminishing the stress component of couples seeking to conceive.16
MacPherson et al conducted a prospective postal audit of acupuncture treatments administered by 574 professional acupuncturists who were members of the British Acupuncture Council.17 They found no serious adverse events after 34,407 acupuncture treatments. In 2001, White et al reported prospective data from 78 physicians and physiotherapists who administered 31,822 acupuncture treatments.18 Altogether, only 43 significant events were reported, giving a rate of 14/10,000 (95% confidence interval [CI] 8-20/10,000). All adverse events had cleared within one week, except for one incident of pain that lasted two weeks and one report of sensory symptoms that lasted several weeks. None of these events was serious. A total of 2,135 minor events was reported, giving an incidence of 671/10,000 (95% CI 42-1,013/10,000) consultations. The most common events were bleeding (310/10,000 consultations, 95% CI 160-590/10,000) and needling pain (110/10,000 consultations, 95% CI 49-247/10,000).
Most recently, Melchart et al conducted a prospective investigation of adverse effects of acupuncture in 97,733 patients receiving more than 760,000 acupuncture sessions.19 The mean (SD) number of inserted needles per session was 12.6 (± 5.1). Mild adverse effects were reported in 6,936 patients (7.10%, 99% CI 6.88%-7.32%). The most frequently reported adverse effects were needling pain and hematoma. Comparison of this adverse event rate for acupuncture with those of drugs routinely prescribed in primary care suggests that acupuncture is a safe form of treatment.20
Acupuncture has a long history in China of being an effective treatment for male infertility. Recent studies conducted in Western countries assessing acupuncture’s effectiveness for this indication support those historical observations.
There is a paucity of methodologically sound studies on the effectiveness of acupuncture in the treatment of male infertility. However, artificial reproductive technologies are highly expensive and have limited effectiveness as well. In this setting, acupuncture with its excellent safety profile, low cost, and reported positive outcomes, may be recommended to patients with male infertility as part of an initial intervention or in conjunction with conventional therapies.
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