Traditional Chinese Medicine and Infertility

By Mike Berkley, L.Ac.

Although health and healing are the common goals of Traditional Chinese Medicine (TCM) and allopathic medicine, their ideas on the etiology of disease and the process used to regain health are decidedly different. The allopathic physician learns that disease must be cured by prescribing medicine, which kills bacteria or renders a virus ineffective; surgical intervention is sometimes necessary.

Though the goal of TCM is to cure a patient, the practitioner of TCM attempts to do this not by treating the disease but rather by treating the whole person, taking into account the various attributes of an individual, which, when combined, account for an individual being sick or healthy. According to the tenets of TCM, a person is more than their pathology. While treating the pathology may yield impressive results, they are commonly temporary.

According to TCM, A person is not represented solely by his or her illness but by the accumulation of every human interaction from birth, including the values and culture from which the individual develops. Emotional experiences, eating habits, work habits, work and living environment, personal habits, and the social milieu contribute to disease. They are factors that, when modified appropriately, may lead to regained health.

Though the Western scientific community has not, to date, arrived at a methodology to use in Chinese medicine research, the veracity and efficaciousness of this medical modality are nonetheless proven by its long history of continued success. More than a quarter of the world's population regularly uses TCM in their healthcare regimen. Chinese medicine is the only form of classical medicine that is regularly and continuously used outside of its country of origin.

The Four Examinations

The 'Four Examinations' is a method of diagnosis that dates back over three thousand years. Observing, Listening, and Smelling (Listening and Smelling are counted as one of the Four Examinations), Questioning and Palpating make up the 'Four Examinations.' This method of diagnosis is far from simplistic, allowing the practitioner to arrive at a differential diagnosis.

Each of the "Four Examinations" can take years to master. While these diagnostic tools are not replacements for that which Western medicine can provide in analyzing and treating disease, they can offer information that, when understood in the context of TCM, provides additional opportunities to map out disease patterns and arrive at treatment success.

The practitioner of TCM must approach a patient with a clear and calm mind, without a preconceived diagnosis and etiology.

This mindset will enable the practitioner to yield clinical gems and clues about the individual who sits before us! This is the stuff of TCM.

The subjective, interpretive, and objective evidence of an individual obtained via the 'Four Examinations' leads to the discovery of the etiology of disease while concomitantly opening a window to the 'Whole Person", thus revealing where in the individual's life the pathogenesis started and what initiated it. The practitioner of TCM must utilize his interpretive skills, which consider what is verbalized by the patient and what is observed while considering what the patient does not verbalize.

Often, that which is not said can be as clinically enlightening as the information freely provided. The tone of the voice, the complexion, and the condition of the eyes (in TCM, the Shen or spirit of an individual is said to be revealed through their eyes). Who can deny the clinical efficacy of this? Is there a different expression revealed through the eyes of a clinically depressed individual than those of a happy, well-adjusted one?) The Chinese medicine doctor observes and utilizes facial expressions, overall demeanor, and how one walks, sits and stands as part of the information required to diagnose a differential. The TCM practitioner must be able to note inconsistencies in an individual expressed by the patient even without the patient being cognizant of the chasms between what they verbally express and what their spiritual presentation divulges. The sensitivity to and awareness of these human idiosyncrasies enables the TCM practitioner to understand who the patient is even before the 'main complaint' is discussed.

Proper treatment in TCM is more than the elimination of pathological processes. In addition to attacking a pathological factor(s), it is the responsibility of the TCM practitioner to support the individual in his or her goal of achieving overall health, which includes aspects of physical-psycho-emotional and spiritual health. This paradigmatic approach is an inexorable part of the process of healing. Without it, we merely chase the sickness and forget about the patient. With this approach, the patient is seen as a whole person, representing the sum of a lifetime of experiences, not just an embodiment of pathology.

Pathologies are guests (and we hope temporary ones!) in a home that serves as a gracious host - our physical, emotional, and spiritual selves. TCM is first concerned with strengthening the immune function, which includes homeostasis of the patient's physical, emotional, and spiritual attributes, to assist the patient in battling and destroying the enemy at the gates (or inside them).

When people are chronically exhausted from lack of sleep resulting from anxiety or depression, they can become chronically sick due to a lowered immune system.

In TCM, the point of departure from Western medicine is not to view the acute presentation (called "the branch" in TCM) as primary but to treat the etiology (called "the root" in TCM), which is the anxiety and depression which causes insomnia then facilitating exhaustion and lowering the immune function which can lead to chronic illness.

So, rather than prescribing antibiotics repeatedly, we might address the patient's anxiety/depression syndrome or refer them to a psychotherapist for appropriate intervention while simultaneously providing treatment.

Infertility and TCM - Mechanisms of Action

It was shown in a study done at Harvard that stress reduces the hypothalamic-anterior pituitary-ovarian axis function, thus being a factor to be considered in the infertility work-up. Acupuncture releases endorphins which mitigate one's response to stressful stimuli, thus enhancing the possibility for conception.

"Historically, infertility, particularly "functional" infertility, was attributed to abnormal psychological functioning on the part of one or both members of the couple. Preliminary works in the 1940s and 1950s considered "psychogenic infertility" as the primary cause of failure to conceive in as many as 50% of cases. As recently as the late 1960s, it was commonly believed that reproductive failure resulted from psychological and emotional factors. Psychogenic infertility was supposed to occur because of unconscious anxiety about sexual feelings, ambivalence toward motherhood, unresolved oedipal conflict, or conflicts of gender identity. Fortunately, advances in reproductive endocrinology and medical technology, as well as in psychological research, have de-emphasized the significance of psychopathology as the basis of infertility, and modern research shows that there is little evidence to support a role for personality factors or conflicts as a cause of infertility. This perspective unburdens the couple by relieving them of the additional guilt of thinking their mental stress may be responsible for their infertility.

Biologically, since the hypothalamus regulates both stress responses and the sex hormones, it's easy to see how stress could cause infertility in some women. Excessive stress may even lead to complete suppression of the menstrual cycle, and this is often seen in female marathon runners, who develop "runner's amenorrhea." In less severe cases, it could cause anovulation or irregular menstrual cycles.

When activated by stress, the pituitary gland also produces increased amounts of prolactin, and elevated prolactin levels could cause irregular ovulation. Since the female reproductive tract contains catecholamine receptors, catecholamines produced in response to stress may affect fertility, for example, by interfering with the transport of gametes through the fallopian tube or altering uterine blood flow. However, more complex mechanisms may be at play, and researchers still don't completely understand how stress interacts with the reproductive system. This story is still unfolding, and during the last 20 years, a new field of psychoneuroimmunology has emerged, focusing on how your mind can affect your body.

Research has shown that the brain produces particular molecules called neuropeptides in response to emotions, and these peptides can interact with every cell of the body, including those of the immune system. In this view, the mind and the body are connected and inseparable, so it is hardly surprising that stress can negatively influence fertility.

Stress can reduce sperm counts as well. Thus, testicular biopsies obtained from prisoners awaiting execution, who were obviously under extreme stress, revealed complete spermatogenetic arrest in all cases. Researchers have also shown significantly lower semen volume and sperm concentration in a group of chronically stressed marmoset monkeys, and these changes were attributed to lower concentrations of LH and testosterone (which were reduced in the stressed group). However, how relevant these research findings are in clinical practice is still to be determined. (i) "

The stress factors that acupuncture addresses stem from both psycho-emotional and physical etiologies. For example, extremely painful pre-menstruum or mid-cycle pain can be debilitating. This type of physical stress, no doubt, produces emotional stress due to missed work, manifest pain, and other lifestyle factors resulting from such extreme pain; all can mitigate the function of the reproductive system.

Aceto corticotropic hormone is released as a response to acupuncture needle stimuli. ACTH has an antiinflammatory mechanism that may, for example, help with tubal factor-based infertility as a response to pelvic inflammatory disease, assuming that the tubes are not scarred.

The insertion of acupuncture needles has been shown to increase blood circulation effectively. Acupuncture is very effective in treating, for example, Reynaud's Syndrome. Enhanced microcirculatory patency to the uterine lining does, undoubtedly, contribute to a healthier and more growth-oriented endometrium, especially when utilizing electrical stimulation on inserted acupuncture needles on points known as zigongxue which reside superior to the ovaries. The points zigongxue are located 3 inches inferior to the umbilicus and three inches bilateral to the anterior midline.

"They reviewed existing evidence regarding the role of acupuncture in the treatment of infertility and identified several studies indicating that acupuncture can be beneficial as an adjunct to other infertility treatments, including IVF. Only one randomized controlled study examined the independent effect of acupuncture on IVF outcomes, but this indicated a positive effect.

The reviewed authors also highlight evidence that acupuncture's effects may be mediated through neuropeptides that influence gonadotropin secretion, which could, in turn, affect the menstrual cycle. The technique can also reduce stress, which affects fertility adversely, and has been implicated in regulating uterine blood flow." (ii)

"Using acupuncture during assisted reproduction may improve pregnancy rates, say researchers. However, they acknowledge that the mechanism behind this effect is unclear, and the team plans to conduct further studies to confirm and further investigate their findings.

Noting that acupuncture has been shown to affect the autonomic nervous system, Dr. Wolfgang Paulus (Christian-Lauritzen-Institut, Ulm, Germany) and colleagues postulated that the therapy could increase endometrial receptivity via control of related muscles and glands.

The researchers randomly assigned 160 women receiving assisted reproductive therapy to undergo IVF with or without acupuncture before and after embryo transfer. In acupuncture subjects, the needles were placed at points believed to influence reproductive factors, for example, by improving uterine blood flow. Paulus et al. report that the acupuncture group had a higher pregnancy rate than those not given acupuncture (43 percent versus 26 percent). They conclude, therefore, that acupuncture could be "a useful tool" for improving pregnancy rates during specific infertility treatments." (iii)

A Diagnostic Window - East Meets West

One TCM diagnosis that may be etiologic for male or female infertility is called Liver qi stagnation. One of the key identifiers of an individual with the pattern differentiation of Liver qi stagnation is anger, rage, frustration, depression, and anxiety.

"Symptoms of depression, anxiety, and anger may help determine the nature of infertility experienced by some couples, and identify those who would benefit most from psychological counseling, suggest researchers.

Dr. Secondo Fassino (University School of Medicine, Turin, Italy) and colleagues recorded the personal characteristics of 156 infertile and 80 fertile couples and measured their degree of psychopathology. When the researchers divided the couples according to the nature of the infertility-organic, functional, or undetermined-they, they found that the triad of anxiety, depression, and a tendency toward anger suppression successfully predicted the diagnosis of organic or functional infertility in women, with 97 percent accuracy.

Anxiety was also a significant independent predictor of functional infertility for infertile men, increasing the likelihood of having this form of infertility five-fold. At the same time, depression was more predictive of organic infertility. However, with men - unlike women - anger did not appear to influence infertility in men.

The results suggest the possibility of identifying a subgroup of infertile subjects where, beyond the distress that is consequent to the failure of repeated attempts to conceive a baby, there is also a poorly adaptive psychological functioning, which is likely to play an essential role in the onset and course of functional infertility," the team concludes."(iv)

It is becoming more and more prevalent that research conducted by Western scientists and physicians is highlighting the veracity and effectiveness of Traditional Chinese Medicine.

Herbal Medicine

The efficacy of herbal medicine in treating infertility is indisputable to the patient community, although the mechanism of action is not entirely understood now. Similarly, the mechanism of action of tricyclic antidepressants is not fully understood in their effect on chronic pain (i.e., in the case of fibromyalgia), but its efficacy has been maintained.

Practitioners of Chinese herbal medicine rarely use a single herb in treatment. Chinese herbs are formula based; many are mixed to create the perfect 'decoction' specifically designed for the individual patient.

Some formulae contain two herbs, and some thirty or more herbs. Each herb has many functions. Each herb has its own flavor, nature, temperature, and tropism. Prescribing the correct herbal medicine requires extensive training and clinical experience.

Self-medicating with herbal medicine presents a dual dilemma. At best, the herbs will be useless, as the key to correct formula prescription is an accurate differential diagnosis which can only be rendered by a licensed, board-certified, experienced practitioner. In the worst case, self-prescribing herbal medicine may prove harmful.

An excellent example of this is Ma Huang/Ephedra. Ma Huang is an herb prescribed daily by hundreds of TCM practitioners to thousands of patients safely.

That several people have died as a result of taking Ma Huang has nothing to do with the dangerous properties of the herb, but rather with the fact that in all cases of fatalities, the individuals were self-medicating, without directions from a doctor required for appropriate applications and contraindications. Aspirin can also prove fatal if taken by a hemophiliac. This does not indicate that aspirin should be banned or that it is a dangerous drug, but that it is unsafe if misused and safe if used appropriately.

Not only is herbal medicine safe, but it is also highly effective in treating many pathologies without the concomitant adverse effects often accompanying pharmaceutical drugs. There are many hospitalizations and fatalities which occur yearly as a result of adverse reactions to biomedicine. The occurrence of adverse reactions to herbal medicine is far less. (v)

I have used herbal formulae repeatedly to lower elevated FSH levels, regulate irregular menstrual cycles, mitigate pain in the endometriosis patient; mitigate pain in the patient who presents with ovulation and/or menstruation-related migraines; to thicken an unresponsive endometrium; to treat the amenorrheic; the oligomenorrheic patient; and the patient who presents with idiopathic infertility. Additionally, I have successfully treated male factor infertility, which includes presentations such as low sperm count, poor motility, and sperm DNA fragmentation.

Further research is needed to fully understand the mechanisms of action of acupuncture and herbal medicine in treating the infertile patient. Nevertheless, it is my opinion that the best-case scenario for most patients is to offer them every reasonable option which may serve to address their presentation successfully. Based upon the empirical evidence of my practice in which I specialize in treating infertility, the integration of acupuncture and herbal medicine into the treatment protocol from a clinical perspective makes sense.

i Domar, Alice (back)
ii Fertility and Sterility 2002: 78: 1149-53 (back)
iii Fertility and Sterility 2002: 77: 721-724 (back)
iv Human Reproduction 2002; 17: 2986-94 (back)
v Adverse reactions to drugs are very common in everyday medical practice. A French study of 2067 adults aged 20-67 years attending a health centre for a check up reported that 14.7% gave reliable histories of systemic adverse reactions to one or more drugs. In a Swiss study of 5568 hospital inpatients, 17% had adverse reactions to drugs. Fatal drug reactions occur in 0.1% medical inpatients and 0.01% of surgical inpatients. The main drugs implicated are antibiotics and non-steroidal anti- inflammatory drugs. Adverse reactions to drugs occurring during anesthesia (muscle relaxants, general anesthetics, and opiates), although less common (1 in 6000 patients receiving anesthesia), are life threatening, with a mortality of about 6%.
BMJ 1998;316:1511-1514 ( 16 May )(back)

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