What is IVF and TCM?
Fertility declines with advancing age and the number of couples seeking infertility treatment at an older age is constantly increasing. A top quality embryo is believed to have the highest potential for implantation and development into a child. A better understanding of the relative importance of patient and treatment characteristics and of embryo quality could help to optimise the existing therapeutic schemes and the safety of in IVF(In vitro fertilization). Alternative medicine such as Traditional Chinese Medicine(TCM) has been supporting IVF treatments in recent years to boost success rate.
IVF is a technique of reproductive medicine. Following controlled ovarian stimulation (COS), eggs are retrieved from the ovaries. After these eggs are cultivated and fertilized and have developed into embryos of a certain size, they are transferred to the uterus for implantation and growth.
IVF was first successful in the United States in 1981. Since then, it has become a widely accepted method of treatment for infertile couples.
What are the indications for IVF?
There are various causes of infertility, many of which can successfully be treated with IVF. The indications for in vitro fertilization include:
- Tubal Factor (Damage to Fallopian Tubes) / Pelvic Adhesions
- Oligospermia (low sperm count)
- Abnormal cervical factor Immunologic factor—husband or wife
- Diminished Ovarian Function & Age Related Infertility
- Anovulation & Polycystic Ovarian Syndrome (PCOS)
- Unexplained infertility
- Infertility after tubal surgery
- Infertility after treatment for endometriosis
What are the success rate of IVF?
Age is an critical factor in predicting success of IVF treatment. The likelihood of becoming pregnant declines as couples age, but the average age of women seeking fertility treatment has steadily increased over the last 20 years, reflecting the trend for couples to start families later on.
After the age of 42, the chances of IVF success falls sharply. According to Human Fertilisation and Embryology Authority (HFEA), the percentage of IVF cycles that resulted in births decreases from 20% when the mother is aged 38-39, to 14% at age 40-42, to just 5% when she is over 42.
Do I need IVF treatment immediately?
In the following cases, it is advisable for patients to immediately undergo IVF/ET or ICSI/ET treatment, for the sake of saving time:
- For women with blocked fallopian tubes on both sides, or for women whose fallopian tubes were removed in a fallopian tube removal;
- For women who have a prehistory of pelvic tuberculosis because this disorder increases the likelihood of an abdominal pregnancy since the TB has destroyed the inside of the ovaries.
- For women whose partner suffers from severe oligo-astheno-teratozoospermia syndrome (OATS), because here it is impossible to produce a child naturally or via intrauterine insemination (IUI).
Of course, this is a case-by-case basis and every couple has a different fertility history to be assessed.
How can TCM help with Fertility issues?
Usually TCM can achieve good results by diagnosing Chinese pattern identification with biomedical pathology. For example, a female patient whose infertility is accompanied by problems such as endometriosis, PCOS, luteal phase defect (LPD), or dysfunctional uterine bleeding can become pregnant when treated with TCM.
According to my experience, some patients who had previously received various IVF/ET or ICSI/ET treatments with no success were able to have children after treatment only with Chinese medicinals.
I don’t usually ask my patients to discontinue your Western medications and take TCM only. A patient with PCOS, for example, can supplement TCM treatment with Clomifen/hCG or Metformin, to profit from the advantages of both methods. Of course, I will explain in details with the patient to manage expectations.
For patients undergoing IVF/ET, TCM can also be used to support their treatment, which I will explain in more details how TCM can help.
For endometriosis patients, if they are still not pregnant after 3-6months of TCM treatment, laparoscopy is advised. Afterwards, we continue treatment with TCM because the pregnancy rate 6 months after laparoscopy is relatively high. This results either from the stimulation of ovulation or from the additional softening of adhesions and tissue growths, as a result of which the function of the ovaries and fallopian tubes is supported.
I have to emphasise that patients after a laparoscopy should not go without additional treatment. This would reduce the possibility of a pregnancy because these patients often suffer also from lack of ovulation, LPD, luteinized unruptured follicle syndrome (LUFS), or immune problems. Moreover, endometriosis relapses are common.
Good results can also be achieved with TCM in the treatment of male infertility patients in whom sperm density is less than 20 million/mL and sperm activity is reduced. This is suitable for patients who want to conceive naturally or IVF treatment. Either way you need healthy sperms for treatment to be successful.
In the case where I've decided to go for IVF, how can TCM help?
IVF treatment itself is divided into different phases, therefore our TCM treatment are differentiated as well.
I have defined 6 stages where I can help support IVF treatment:
- Preparatory
- Down-regulation
- Menstrual
- Oocyte maturation
- Follicle punction
- Embryo transfer
Stage 1: Preparatory 调 (2-3 months before the start of IVF treatment)
In order to successfully carry out an IVF/ETor ICSI/ ET treatment, it is important to balance the patient’s yin and yang, qi and blood, the viscera and bowels (zang and fu) for 2–3 months by means of TCM.
According to the TCM theory, “the kidneys are responsible for the ability to reproduce (shen zhu sheng zhi 肾主生殖)”. Most infertility patients suffer from kidney vacuity.
In TCM, “the kidneys store the essence (shen cang jing 肾藏精, and “essence and blood share the same source (jing xue tong yuan 精血同源)”. An insufficiency of essence and blood negatively affects the function of the chong mai(冲脉) and ren mai(任脉), known to regulate fertility. Under these circumstances, it is difficult to become pregnant.
On the other hand, though, controlled ovarian stimulation induced the development of a larger amount of follicles within a very short time, which consumes a lot of essence and blood. This in turn causes additional damage to kidney essence and liver blood. Now we know that the man’s essence and the woman’s blood form the material foundation of pregnancy. In this case, how could we expect good results with a precondition of insufficient liver blood and kidney essence?
Shortly after failed IVF/ET treatments, women often describe menstrual disorders such as a delayed or shortened cycle, increased menstrual bleeding, or amenorrhea. In such cases, we must first regulate menstruation before a new IVF/ET treatment is initiated. In TCM, it is believed that the method for achieving pregnancy is to regulate menstruation to plant seeds (tiao jing zhong zi 调经种子). It is certainly easier to become pregnant when menstruation is regular. From the biomedical perspective, a regular menstrual cycle is the result of the proper interplay of hypothalamus, hypophysis, and the ovaries. To regulate menstruation means to regulate this connection (the reproductive axis).
Hormonal imbalances in the body after a failed IVF/ET treatment can affect the interplay of the body’s own hormones and disrupt the maturation of the ovum and the construction of the endometrium and development of the embryo. In this case, it is good to regulate the imbalances in the body for 2–3 months with TCM and to allow the body to recuperate before the start of another IVF treatment.
As a result from the stress from IVF treatment, many patients suffer from liver qi stagnation. The causes of this can consist of: long-lasting infertility, failed IVF/ET treatments, excessive expectations, but also the increasing pressure and psychological strain from family, society, and the patient’s professional and economic situation. Liver qi stagnation leads to disturbance in the qi and blood, which in turn affects the function of the liver and kidney because “the liver and kidney share the same source” (gan shen tong yuan 肝肾同源). If such women continue biomedical treatment immediately after a failed IVF/ET attempt, an additional failure will further aggravate the stagnation, which causes a vicious circle. Therefore, more and more failures result. This is called “infertility due to liver depression” (gan yu bu yun 肝郁不 孕).
Some patients suffer from depression or nervous agitation, which gives rise to or aggravates additional symptoms like exhaustion, insomnia, or changes in appetite and weight. After a failed IVF/ET treatment, we recommend treating the patient for 2–3 months with TCM to regulate and harmonize.
These deviations from the ideal state provide the explanation for a continued lack of pregnancy in spite of the fact that the biomedical preconditions, for example, an endometrial thickness of 10 mm, good embryo morphology, and an optimal hormonal state,are fulfilled. TCM always treats the whole person. A healthy appetite and sleep, balanced emotional state, and regular digestion are good and important signs for the patient.
Stage 2: Down-regulation Phase—Supplementing (Bu 补)
In this phase, the patient receives high doses of GnRH-a (gonadotropin-releasing hormone agonist), often known as a “long protocol”, to inhibit the activityof the reproductive axis and the body’s own hormones. This is called down-regulation and often begins in the luteal phase of the previous cycle. Patients with endometriosis and adenomyosis are treated for 2–3 months to control the endometriosis lesions. Patients with an irregular cycle or FSH (follicle-stimulating hormone) levels of more than 15 U/L are often given the “pill,” for example Marvelon, for 1–3 months prior to the start of IVF/ET treatment. This protocol is increasingly ditched in favour of the ‘short protocol’, and is usually done for patients with low follicles extraction.
The purpose of TCM during the “down-regulation phase” serves to replenish and supplement blood and essence without stimulating the reproductive function, which would run counter to the downregulation by GnRH-a. My purpose of giving TCM is NOT to replace the function of GnRH.
Stage 3: Menstrual Phase—Gently Free the Blood (Tong 通)
During this phase, the menstrual blood is flowing. Menstruation is the beginning of a new cycle. During this time, it is important to “drain instead of storing” (xie er bu cang 泻而不藏) and to “create a smooth passage by freeing the flow” (yi tong wei shun 以通为顺). The blood should be freed and purged gently to cause the old endometrium to be eliminated completely and thereby ensure that the new endometrium can grow in a renewed environment. Treatment begins 2–3 days before the onset of menstruation and continues for another 3–4 days afterwards to nourish blood and support the flow of blood to regulate menstruation. Acupuncture treatment also starts here.
Stage 4: Oocyte Maturation Phase—Promoting (Cu 促)
This phase corresponds to the length of time that the patient is taking gonadotropin-FSH or hMG (human menopausal gonadotropin) to stimulate the maturation of the oocyte. My aim now is to warm and supplement the kidneys, quicken the blood, and regulate the chong mai and ren mai, to promote oocyte maturation.
Stage 5: Follicle Punction Phase—Relax (Song 松)
This phase begins at the point in time when the follicles are almost fully matured and lasts until 1 day before the embryo transfer (ET). During this time span, patients undergo a variety of tests (blood tests, ultrasound, etc.) and surgeries; they are therefore often very tense. TCM helps to regulate liver qi, strengthen the kidney and move the blood.
Stage 6: Embryo Transfer Phase—Securing and Astringing (Gu 固)
This phase comprises the time span from the embryo transfer to the serum hCG test (pregnancy test) after 12–14 days. Treatment aims to replenish the kidneys and spleen to boost the chong mai and ren mai for a better pregnancy.
Current research on acupuncture for IVF
1. Safe, even during pregnancy
Acupuncture has been found to be relatively safe among general patient populations[1] and also among women at various stages of pregnancy[2], it is low cost, and, if effective in increasing IVF success rates, could potentially reduce the need for an additional high cost IVF cycle.
2. Reduces stress in patients
Furthermore, qualitative research suggests that adjuvant acupuncture may help IVF patients deal with the psychological and emotional issues that accompany both subfertility and IVF treatment [3].
An 8‐week randomized controlled trial (RCT) examined the effect of acupuncture on psycho‐social outcomes for women experiencing infertility and found there were benefits with reducing infertility stress.[4]
3. Improved pregnancy rates
In 2002, Paulus etal.first published the results of th erandomized controlled trial investigating the effects of acupuncture on pregnancy rates of IVF patients. In this trial, 160 healthy women undergoing IVF or intracytoplasmic sperm injection (ICSI) were randomized to receive acupuncture or no acupuncture.
Acupuncture was administered 25 minutes before and after Embryo Transfer. Higher pregnancy rates were found in the acupuncture group compared with the group that did not undergo acupuncture[5].
4. Reduce miscarriage rates
Magarelli and Cridennda carried out a retrospective clinical study and reported higher pregnancy rates(51% versus 36%, 𝑃 < 0.05) and lower miscarriage rates (8% versus 20%, 𝑃 < 0.05) among those subjects who received acupuncture compared with subjects in the control group[6]
5. Improve egg quality
Cui et al. study confirmed that patients of IVF-ET accepted the intervention of EA, their egg quality can be improved, and the pregnancy rate was increased [7,8].
6. Improved implantation rates
Stener-Victorin conducted a randomized controlled multicenter and prospective study; the results confirmed that the EA group achieved a higher implantation rate, pregnancy rate, and birth rate than control group in these patients undergoing IVF-ET[9].
7. Regulate menstrual cycle and reduce anxiety
Regarding the potential mechanisms of acupuncture effect on fertility,the following points deserve careful consideration.The first point is that acupuncture may mediate the release of neurotransmitters, which may influence the menstrual cycle,ovulation, and fertility by stimulating the secretion of gonadotrophin-releasing hormone. Acupuncture was well known for its effect of releasing 𝛽endorphin in the central nervous system, and 𝛽-endorphin levels could influence the secretion of steroid hormones, regulate the menstrual cycle and ovulation [10], and reduce anxiety of infertile couples [11].
Both acupuncture and EA have been proved that could increase the levels of several neurotransmitters such as 𝛽endorphin inhibiting the perception of pain and playing a positive effect on the outcomes of IVF [12].
8. Regulate hormonal levels
Some authors have shown that acupuncture may influence plasma levels of follicular stimulating hormone,luteinizing hormone, estradiol, and progesterone, improving ovulation rates [13]. These results have also been proven by animal studies that acupuncture can normalize the secretion of GnRH and influence peripheral gonadotrophin levels[14].
9. Improve blood flow to uterus
Acupuncture may promote blood flow to the uterus by inhibiting uterine central sympathetic nerve activity and may promote the endometrial receptivity. A successful implantation of human embryos into the uterine cavity was effected by several important parameters, such as endometrial thickness, morphology, and uterine artery blood flow. High arterial blood flow impedance and low uterine perfusion result in low implantation rate [15]. Acupuncture can contribute to the reduction of impedance of the uterine artery by inhibiting central sympathetic nerve and then improve the blood flow to the uterus [16]. EA also can reduce the blood flow impedance index of uterine artery of infertile women and increase the blood perfusion of the endometrium, to provide some good conditions for embryo implantation and improve pregnancy rate. Studies have reported that EA could increase uterine blood flow in infertile women[17].Stener-Victorinetal. demonstrated positive effects of EA on the pulsatility indices (PIs) of IVF patients and further found higher pregnancy rates (45.9% versus 28.3%; 𝑃 < 0.05) in the EA group compared with a group that used conventional analgesics during oocyte aspiration [17]
Current research of moxibustion on IVF patients
Moxibustion originated from the periods of spring and autumn and the Warring States in ancient China. Moxibustion could warm meridians, relieve pain, and promote blood circulation by burning compressed herbal material at the acupoints.
1. Improve pregnancy rates
Modern studies confirmed that moxibustion can regulate functional activity of whole body’s organs and enhance immune function,increasing the chance of pregnancy [18].
2. Improve blood supply to pelvic area
Related studies have confirmed that moxibustion can improve pelvic blood circulation and increase pelvic blood perfusion, regulate the function of hypothalamic-pituitary-gonadal axis and the secretion of steroid hormones, and promote the follicular development and pregnancy rate [84, 85]. A recent prospective, randomized controlled clinical trial indicates that, when embryo implantation has failed, use of acupuncture and moxibustion as adjuvant treatments in women undergoing IVF significantly improves pregnancy outcomes. This study was conducted with 84 infertile patients who had at least two unsuccessful attempts ofI VF.The patients were randomized in control, sham, or acupuncture group. Acupuncture was performed on the first and seventh day of ovulation induction,on the day before ovarian puncture,and on the day after embryo transfer. In the acupuncture group, patients were treated with moxibustion and needling. In the sham group needles were inserted in the areas that did not correspond to known acupuncture points. As a result,the clinical pregnancy rate in the acupuncture group was significantly higher than that in the control and sham groups(35.7% versus 7.1% versus 10.7%; 𝑃 = 0.0169)[19].
Current research on Chinese Herb Medicine(CHM) for IVF
Chinese medicine is a medical system that has existed for an estimated 3000 years. Near the turn of the last century, the Chinese systematized various Chinese medicine practices into one unified medical system that could best be integrated with Western medicine and called it traditional Chinese medicine (TCM). TCM includes a series of traditional medical practices originating in China. It is considered as a complementary and alternative medical system in most of the Western countries while remaining as a form of primary care throughout most of Asian countries. TCM is a comprehensive system for the assessment, as well as for the preventative health care and maintenance. TCM theory is extremely complex and originated thousands of years ago through meticulous observation of nature, the cosmos, and the human body.
Some studies show that 17% of the couples had utilized herbal therapy for infertility in the United States and 46% of patients undergoing IVF admitted regular use of CHM in Irish [20].
1. Improve pregnancy rate
Recently, some RCTs have shown that adjuvant treatment with CHM during IVF-ET could significantly increase pregnancy rate [21]. There have a different effect on pregnancy outcome for those patients undergoing IVT-ET when adjuvant treatment with CHM in the different time points of IVF-ET. Some studies have shown that the patients undergoing IVF-ET can get higher pregnancy rate from CHM treatment if they received earlier treatment with CHM [22]
2. Improve implantation rate and live birth rate
Chen et al. found that treatment with CHM before IVF-ET could significantly increase the implantation rate and live birth rate compared with control group without CHM treatment [23].
3. Improve oocyte quality
Liu et al. randomized 82 cases of endometriosis (EM) who will undergo IVF-ET to CHM group and control group; CHM group received 3-month treatment with CHM before IVF-ET; control group did not receive any treatment before IVF-ET; results showed that CHM could improve the oocyte quality and embryo quality and resulted in a higher pregnancy rate in CHM group than in the control group[24].
4. Reduce miscarriage rate
A study has shown that treatment with CHM after embryo transfer can significantly reduce the miscarriage rate due to the protective action to the fetus from herbal prescriptions [25].
5. Reduce OHSS
OHSS(ovarian hyperstimulation syndrome) is a common complication during the period of IVF-ET,adjuvant treatment with CHM during IVF-ET, that not only could increase the pregnancy rate but also could decrease the OHSS rate. Lian et al. found that those patients adjuvant treatment with CHM could obtain a lower OHSS rate than those patients without CHM treatment during undergoin gIVF-ET [26].
What to expect on your first visit to Green Sinseh
After explaining in detail, I hope you now have a clearer picture of how TCM can support your IVF cycle.
If you have booked an IVF treatment date with your doctor, and would like to book a consultation with me, please bring the following on your first visit.
- Ultrasound scan report
- Laparoscopy report(if any)
- Current medications
- Hormonal Profile (LH, FSH, Progesterone, Testosterone, Thyroid Hormones,AMH and Prolactin, if any)
- Semen Analysis of your husband
Your treatment plan will usually involve:
- TCM herbal prescriptions (3 packets per week dosage)
- Acupuncture (if you are willing)
- Moxibustion (if you are willing)
- Adherence to a diet that will nourish your body and support IVF
Book an appointment to find out how I can help support you on your IVF journey.
References
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