In vitro fertilization is a procedure which brings hope to couples unable to conceive naturally. Successful implantation and continuation of pregnancy is the ultimate goal of this procedure. Acupuncture, due to its local and systemic effects, presents ecologically sound and ideal conditions for implantation of the ovum. A case report of effective acupuncture treatment, both pre and post embryo transfer, which resulted in pregnancy is presented.
M. Nandagopal, MD, FFARCS( I )
A. Fargas-Babjak, MD, FRCP(C)
S. Oomman, MD, FRC
Procreation is a natural desire of every living being and brings with it the continuity of the species. The happiness and joy of bearing a child is important to many childless couples who go from pillar to post, from one physician to another, in an effort to conceive. With the advancement of knowledge and technology now they are offered procedures like in vitro fertilization (IVF) and intra cytoplasmic sperm injection techniques. In these procedures the woman’s egg is harvested and fertilized with a man’s sperm in a laboratory. The embryos which are developed from the fertilization are then transferred into the woman’s womb. The pregnancy rates of these procedures are around 26.3%. Therefore, the woman may be faced with a prospect of repeated attempts of embryo transfer which could prove to be an immense strain both psychologically and physically.
Acupuncture as a therapeutic modality has been utilized for thousands of years in China. According to traditional ideas, acupuncture points are located along specific meridians or channels. Inserting fine acupuncture needles at these points is considered a method of balancing the body’s energy or Qi to prevent or cure illness.
Our understanding and knowledge of brain and body function and their interaction, specifically in pain physiology and stress response, has expanded and increased over the last few decades. Acupuncture is a peripheral sensory stimulation technique and has been shown to alter and modulate central nervous system activity, and induce different endogenous opioids and monoamine release.1
There is evidence to support the use of acupuncture in treatment of various states of disregulation like nausea and vomiting.2 Recent work supports the concept that acupuncture activates the endogenous opioids in the central nervous system which in turn inhibits the central sympathetic neural outflow.3
The NIH Consensus Conference2 also stated that there is sufficient evidence of acupuncture’s value to expand its use into conventional medicine and treatment of female infertility. Combining the IVF technique with acupuncture shows an increase in the pregnancy rates up to 42.5%.4
A thirty year old healthy female patient came for IVF treatment. Her thirty eight year old husband was diagnosed to have oligospermia. This was her first attempt for IVF.
During this period she was already attending acupuncture sessions for a few weeks from a naturopath who practiced traditional Chinese medicine techniques. The acupuncture points that she was given were Conception vessel CV3 and CV4 on the abdomen, and on the back she was given alternating Shu points relating to the Kidney and Spleen meridian. She also received influential blood points, like Bladder BL23, BL20 and BL17, and in the foot the points were Kidney K3, K6 and K7. With this ongoing acupuncture she was referred to the McMaster acupuncture clinic for further care and treatment.
On the day of the IVF procedure, the patient received manual acupuncture stimulation for twenty five minutes before the embryo implantation. The points selected this time were based on the McMaster modular approach of the western acupuncture method. The local points given were CV3, CV4, Spleen SP8, Stomach ST25, and ST29. The corresponding segmental axial points extended from Thoracic T10 to Lumbar L2 para vertebral level for the sympathetic and Sacral S2, 3, and 4 for the parasympathetic outflow. The distal extra segmental points were Governor Vessel (GV20), Pericardium (PC6), and Liver (LR3). In the ear microsystem points like uterine, sympathetic, endocrine, thalamus and stress reduction points were stimulated.
After the embryo transfer another session of manual acupuncture was given for fifteen minutes. The points used now were Large Intestine LI4, Stomach ST36, Spleen SP6, and SP10, and all the systemic regulatory points in her feet. After 6 weeks ultrasound confirmed the presence of a fetal sac in the uterus. At present she is nine months pregnant and is due for delivery any day.
Infertility and its consequences can very much take over a person’s life. Social stigma and stress further damages an overwrought and anxious person to no gain. For a successful pregnancy using IVF there are many factors involved which are diverse in nature such as the cause of infertility i.e. whether it is structural or functional, the age of the woman, the skill of the technician performing the procedure and ideal conditions for embryo implantation.
Research has proved that acupuncture produces an effect both centrally andperipherally thus preparing the uterus for successful implantation of the embryo. Acupuncture acts by causing opioid peptide release; it also stimulates the hypothalamus and pituitary to release hormones and neurotransmitters into the blood stream producing a broad spectrum of systemic effects. b-endorphin which is released during acupuncture is derived from proopiomelanocortin which is present in the arcuate nucleus of the hypothalamus, the pituitary, medulla and peripheral tissues including intestines and ovaries.1 It is known that the opioid peptide affects the release of the Gonadotropin releasing hormone which is released by the hypothalamic pituitary axis and plays a major role in the menstrual cycle by controlling the FSH and LH release. These hormones influence the maturation and release of ovum from the ovary which also produces oestrogen and progesterone hormones for the preparation of the endometrium for embryo implantation and maintenance of pregnancy.5 Hence we can say that it is logical to hypothesize that acupuncture may influence ovulation and fertility.
Acupuncture is well known for reducing stress and anxiety possibly through its sympathoinhibitory properties. By avoiding the side effects of anxiolytic and anti depressant drugs acupuncture may provide an excellent alternative for stress reduction. As summarized by researchers, acupuncture can improve the success rate of IVF in many ways. Its acts by improving the function of the ovaries,6,7 regulating the hormone levels, increasing the blood flow to the uterus and increasing the thickness of the uterine wall. It also decreases stress and keeps the patient more relaxed, preventing the uterus from contracting. It strengthens the immune system and decreases the chances of miscarriages etc.5
Chen and Yu showed that electroacupuncture normalized the hypothalamic pituitary ovarian axis and in another study Chen reported that six of thirteen anovulatory cycles responded to acupuncture treatment.8
Elizabet Stener-Victorin evaluated the use of electroacupuncture for ovulation induction on 24 patients with poly cystic ovarian syndrome given for three months. The basal body temperature was recorded three months before and three months after electroacupuncture. Main outcome was that electroacupuncture induced regular ovulation in more than a third of the women. Elizabet also noted that high impedance in the blood flow of uterine artery reduces the pregnancy rate of IVF. She gave electroacupuncture to ten healthy but infertile patients. The patients received two sessions per week for four weeks, significant reduction p<0.0001 in pulsatility index which was maintained for two weeks was seen.6,7
A German study done by Paulus et al4 compared pregnancy rates in a total of one hundred and sixty patients undergoing IVF. Acupuncture was done in eighty patients twenty five minutes before and after embryo transfer. The clinical pregnancy rate for the acupuncture group was 42.5% as compared to the control group of 26.3%. Subsequent studies have shown that several sessions of acupuncture treatment may increase the success rate of IVF pregnancy.10
Acupuncture seems to be a useful tool for patients trying to increase their chances of becoming pregnant following assisted reproduction therapy. This additional therapy is cost effective with minimal side effects. Acupuncture is non toxic and relatively affordable and effective so it becomes very attractive for this group of patients.