A Secondary Infertility Case Study
Western Medicine Overview
Infertility is defined by the inability to achieve a pregnancy after 12 months or more of regular unprotected sexual intercourse. Secondary Fertility is considered the inability to conceive after one has already successfully conceived and had a live birth. Infertility is considered a disease of the male or female reproductive system or unexplained factors (World Health Organization: WHO, 2024). Infertility causes due to the female reproductive system include: tubal disorders including untreated STIs, abdominal or pelvic surgical complications or postpartum sepsis; uterine disorders which could be inflammatory like or endometriosis, congenital like a separate uterus or benign like fibroids; ovarian disorders like PCOS; or endocrine system disorders that impact the hypothalamus or pituitary glands (World Health Organization: WHO, 2024). In the male system, causes can include: obstruction of the reproductive tract; hormonal disorders; testicular failure to produce sperm or abnormal sperm function and quality (World Health Organization: WHO, 2024). Around 17.5% of the adult population, roughly 1 in 6 worldwide experience infertility and approximately 10.5% of women aged 20-44 with a prior live birth experience secondary infertility (World Health Organization: WHO, 2023).
Western Medical treatment options for female infertility include: clomiphene citrate, letrozole, gonadotropin-releasing hormone analogs, follicle-stimulating hormone, metformin, and aromatase inhibitor (Stanford et al., 2013). Male infertility treatments include: selective estrogen receptor modulators, gonadotropins, aromatase inhibitors, phosphodiesterase-5 inhibitors, antioxidants, dopamine agonists, kallikrein, indomethacin, low-dose corticosteroids, alpha-blockers, and nitric oxide donors (Kaltsas, et al., 2024).
A 2021 meta-analysis looked into the impact of lifestyle factors and practical recommendations on fertility. The review showed a negative impact of behaviorally modifiable lifestyle factors such as fat-rich diets, delayed childbearing/age of starting family, smoking, alcohol misuse, sexual behavior, anxiety or depression and beliefs were associated with fertility. The study afforded recommendations to enhance fertility for both partners like quitting smoking, maintaining a healthy weight to positively impact hormones and ovulation, reducing or abstaining from alcohol use, reducing stress, eating a balanced diet, getting regular exercise, limiting recreational and prescription drug use, looking into conceiving around age 30 for women and 35 for men, and limiting excessive irradiation from the use of electronics. (Emokpae and Brown, 2021)
Infertility and Chinese Medicine
Acupuncture and Chinese herbal medicine may positively impact fertility outcomes in those diagnosed with infertility. One 2022 systematic review of acupuncture as a treatment for infertility reviewed 27 studies with 7676 participants. The results showed that the intervention group contributes more in statistically significant outcomes than the control group including live birth rate, clinical pregnancy rate, biochemical pregnancy rate, ongoing pregnancy rate, and implantation rate. Interventions included acupuncture, electroacupuncture, auricular acupressure, and acupuncture with moxa. The studies compared real acupuncture vs sham acupuncture or acupuncture versus blank controls. The greatest results were seen in participants with secondary infertility. (Quan et al., 2022)
A 2023 systemic review and meta-analysis of 25 trials with 4757 participants demonstrated pooled CPR of all the acupuncture groups (43.6%) was significantly higher than that of all the control groups (33.2%, P < 0.00001), and the pooled LBR (11 trials) of all the acupuncture groups (38.0%) was significantly higher than that of all the control groups (28.7%, P < 0.00001). Treatments included: acupuncture, electroacupuncture and transcutaneous acu-point electrical stimulation. Acupuncture timing (before or during the time of controlled ovarian hyper-stimulation and around the time of embryo transfer), and acupuncture courses (at least 4 sessions) have respectively positive effects on IVF outcomes. The authors found that acupuncture can significantly improve CPR and LBR among women undergoing IVF with primary and secondary infertility. (Xu et al., 2023)
A 2015 meta analysis of 40 studies involving 4247 women with infertility suggested a 1.74 higher probability of achieving a pregnancy with CHM therapy than with western medicine therapy alone. The trials evaluated included women with PCOS, endometriosis, anovulation, fallopian tube blockage, or unexplained infertility. Furthermore, mean pregnancy rates in the Chinese Herbal Medicine group were 60% compared with 33% in the WM group. (Ried 2015)
Case Report
The client is a 34 y/o female presenting for acupuncture for Secondary Infertility. She had 1 full term pregnancy and has a toddler. She had an abortion at 19 y/o. For the past 2.5 years she and her husband have been trying to get pregnant. They have had 2 failed IVF attempts. They are beginning the final attempt. The client is preparing for an antagonist protocol which includes FSH, a gonadotropin releasing hormone antagonist, hCG and Lupron. The client is currently on estrogen. She is currently taking folic acid, coQ10 and zinc.
Menstruation began at age 13 and was WNL. Menstruation is scanty with menstrual cramps, moderate clots and a long cycle 30-33 days. Warm compresses and baths help relieve discomfort. The client has a dull complexion. Client reports very low libido and coldness throughout the body. She has a history of chronic mid back pain which is worse recently, because of lifting the baby. She reports fatigue. BBT’s have been lower than IVF clinic wants.
The client has anxiety due to fertility, her toddler and her husband’s business, which keeps him out of the home frequently. She reports poor sleep The client has no other significant medical history. The client’s husband, also a client, smokes 1 cigar daily. He has no other significant medical history. He is not on any medications. There is no history of STI for either partner.
Objective findings:
Pulse: Choppy, Deep, especially weak in rear positions
Tongue: Pale, Swollen
Abdomen: Cool Lower Jiao, GB 25 (KI Mu) - tender R>L, abdomen soft to touch
Five Element: Putrid, Fear, Blue, Groan - Water CF
Western Diagnosis: Secondary Infertility, Dysmenorrhea
TCM Diagnosis: Liver Blood Stasis with Kidney Yang Deficiency
Treatment Principles: Regulate the Menses, Invigorate Liver Blood, Tonify Kidney Yang, Warm the uterus
NOTE: I wasn’t able to prescribe herbs for this client based on the fertility clinic, but I have listed what I might have recommended given the opportunity.
Initial Treatment: Clear Aggressive Energy, Clear Pulse Block between LV and LU, KI24 spirit burial ground to soothe the emotions, Source points on Water KI3, BL64 - Pulse Block Cleared and Overall smoothed.
Treatment Plan: anticipated month 1 (which ended up being months 1-3 as the client did not menstruate in the first month of estrogen treatment)
Phase 1: Invigorate Blood - Acupuncture: Face Up: Chong Mai SP4 and PE6, KI14, SP10, LV3, SP6, GB34; Face Down: Four Flowers BL17 + 19; Herbs: Ge Xia Zhu Yu Tang - Decoction to Eliminate Stasis below the Diaphragm
Phase 2 and 3: Tonify Kidney Yang - Acupuncture: Face Up: KI13, CV4, SP6, KI3, KI7, Zigong with moxa, Face Down: BL23, BL52, GV4 Ren LU7 and KI6; Herbs: You Gui Wan - Strengthening the Right
Phase 4: Move Qi, Invigorate Blood, Resolve Cold - Acupuncture: Face Up: Chong Mai SP4 and PE6, KI14, SP10, LV3, SP6, GB34; Face Down: Magnificent 6 with Moxa BL17, 18, 20; Herbs: Wen Jing Tang - Warming the Menses Decoction or Stir the Elixir Field
The client also received 5 element acupuncture using tonification technique on the Water constitution as needed for emotional support throughout her care.
32 hours prior to transfer: Paulus Protocol: PE6, SP8, LV3, ST29, GV20, R shen men, L Ear 58, R Ear 34, L Ear 22; 3 hours post transfer: St36, PE6, SP10, LI4, L shen men, R Ear 58, L Ear 34, R Ear 22 done with ear seeds, rather than needles as the client felt too overwhelmed to be needled
Adjunctive Recommendations: 1. Daily Movement, a walk outdoors with toddler 2. 15 minutes for self each day 3. Drink half body weight in ounces of water 4. Kidney Yang foods to include garlic, onions, chives, ginger tea, black beans, walnuts, pistachios 5. Liver Blood Building Foods to include dark leafy greens, beets, red meat, bone broth, eggs 6. Remove technology from the bedroom and no technology 1 hour before bed.
Additional treatments for male partner: The male partner was seen 5 times for Kidney Yang Deficiency. Which included acupuncture points: GV4, CV4, CV6, KI 3, KI7, UB23, UB52 with moxa and tonification.
Discussion:
Infertility is a common pathology that impacts a significant number and men and women. It is a condition that has many root causes from both a western perspective and a Chinese medical perspective. There is a significant interplay between fertility and emotional wellbeing. While IVF is an effective method for some, it was not initially productive for this client. Acupuncture and Herbal medicine have been proven to positively impact pregnancy and live birth rates in coordination with IVF. This case highlights liver blood stasis and kidney yang deficiency which manifested as infertility, scanty menstruation, long cycles, cold body temperature, low libido, dysmenorrhea and insomnia. Treatment aimed to regulate the menses, invigorate the blood, tonify the kidney yang and warm the uterus.
The initial acupuncture sessions focused by menstrual phase to regulate menstruation by invigorating blood in phase 1, tonifying kidney yang in phase 2 and 3, and invigorating blood, moving qi and resolving cold in phase 4. Moxibustion helped to warm the uterus and enhance the yang. The recommended herbs supported the elimination of stasis, strengthening of the kidneys and warming the blood/moving the qi. Treatment effects became evident in the second month of treatment as indicated by a more typical menstrual cycle. Treatment of the male partner in conjunction with the primary female client may have positively contributed to the fertility profile.
Outcomes:
This client was inconsistent with weekly appointments (in the regulation phase) and out of 18 scheduled attended 9. She and her son became ill several times and her stress level remained quite high. The treatment in the first month in combination with hormones did not initially seem positive, but in month 2 and 3 with improved menstruation, less scant, more blood and reduced symptoms, the treatment seemed to take effect. During this time, the client also seemed to be more engaged in her life. After the final treatment which included the post transfer Paulus protocol, the client did not contact the practitioner until just a few days after her baby boy was born, which was a pleasant surprise and an overall positive outcome.
References:
World Health Organization: WHO. (2024, May 22). Infertility. https://www.who.int/news-room/fact-sheets/detail/infertility
World Health Organization: WHO. (2023, April 4). 1 in 6 people globally affected by infertility: WHO. World Health Organization. https://www.who.int/news/item/04-04-2023-1-in-6-people-globally-affected-by-infertility
Stanford, J. B., Martin, J. C., Gibson, M., Birdsall, E., & Brixner, D. I. (2013). Use of clomiphene citrate in the University of Utah Community Clinics. PubMed, 58(5–6), 229–233. https://pubmed.ncbi.nlm.nih.gov/23763008
Kaltsas, A., Zachariou, A., Dimitriadis, F., Chrisofos, M., & Sofikitis, N. (2024). Empirical treatments for male infertility: A focus on lifestyle modifications and medicines. Diseases, 12(9), 209. https://doi.org/10.3390/diseases12090209
Emokpae, M. A., & Brown, S. I. (2021). Effects of lifestyle factors on fertility: Practical recommendations for modification. Reproduction and Fertility, 2(1). https://doi.org/10.1530/raf-20-0046
Quan, K., Yu, C., Wen, X., Lin, Q., Wang, N., & Ma, H. (2022). Acupuncture as Treatment for Female Infertility: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Evidence-based Complementary and Alternative Medicine, 2022, 1–15. https://doi.org/10.1155/2022/3595033
Xu, M., Zhu, M., & Zheng, C. (2023). Effects of acupuncture on pregnancy outcomes in women undergoing in vitro fertilization: An updated systematic review and meta-analysis. Archives of Gynecology and Obstetrics, 309(3), 775–788. https://doi.org/10.1007/s00404-023-07142-1
Ried, K. (2015). Chinese herbal medicine for female infertility: An updated meta-analysis. Complementary Therapies in Medicine, 23(1), 116–128. https://doi.org/10.1016/j.ctim.2014.12.004
Lyttleton, J. (2004). Treatment of infertility with Chinese medicine. Churchill Livingstone.
Maciocia, G. (2011). Obstetrics and gynecology in chinese medicine. Churchill Livingstone.
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