Overview

The following is a case report of a 44 year old female attempting to conceive naturally for the past 2 years without success. A course of acupuncture and moxibustion twice per week for 12 weeks resulted in a successful conception and sustained pregnancy leading to a successful live birth.

Infertility is defined as the inability to become pregnant after one year of attempting conception, but standard practice generally recommends women over the age of 35 years old to be referred for infertility workup after six months of attempting conception. Age related female infertility and subfertility is thought to be due to a combination of hormonal decline and deregulation, our limited and aging oocyte pools, and accumulated environmental and lifestyle factors as we age.

The Huang Di Nei Jing mentions the cycle of female fertility in the first chapter indicating that women reach menarche at around 14 years of age, and are of prime reproductive age peaking at around 28 years of age after which the fecundity begins to decline:

“With seven times seven, the controlling vessel is depleted and the great thoroughfare vessel is weak and diminished. The heaven gui is exhausted” 

This passage is pertaining to menopause and the inability for life to be conceived at around 49 years of age. Chinese medicine and modern biomedical medicine both view the reproductive age to last from the onset of menarche until around mid to late 40’s.

Clinical research

Most acupuncture studies involving fertility have been focused on how acupuncture can support Assisted Reproductive Therapies (ARTs). One study can be found on acupuncture and natural fertility support conducted in Hong Kong by Chui et al. The case series followed 21 women over the age of 30 who had received infertility consultations. The women were treated and observed over the course of two years after which 14 (66.7%) had successfully conceived. The remaining seven that did not conceive were recommended to continue treatment for another two years. A follow up study found that five continued treatments and all five eventually became pregnant. Of those five, three conceived without IVF. One out of the five women received Chinese herbs without acupuncture. Two of the women were 37 years of age and two were 39 years of age. All the women were under 40, but had been diagnosed as “infertile” for many years.

A prospective observational study conducted by Wang et. al. found that acupuncture could have a positive effect on women diagnosed with Diminished Ovarian Reserve (DOR). The researchers tracked plausible change by looking at change in Follicle Stimulating Hormone (FSH), Luteinizing Hormone, serum oestradiol (E2), and FSH/LH ratios as well as symptom scores of the participants. There is a correlation with high FSH in women with DOR. After 12 weeks, the participants had a statistically significant drop in their FSH and an increase in the volume of their menstruation along with decreased irritability. The effects lasted beyond the 12^th week check in.

Case Description

The patient is a 44 year old woman who has been trying to conceive for almost two years. She has a three-year-old daughter whom she was able to conceive naturally. She was 39 years old at the time of her previous conception and conceived after only three attempts. She delivered via Cesarean (C-section) at 37 weeks due to pre-eclampsia and then was instructed to wait at least one year before trying to conceive again. She waited for one year as was instructed and has been trying to conceive ever since. When she began treatments at the end of April she had been trying to conceive for a full two years. She had received acupuncture for several months for chronic musculoskeletal pain and tension but was curious whether acupuncture could improve her chances of conceiving. I indicated to her that there were several issues that needed to be addressed including hormonal and menstrual regulation, and directing Qi and Blood to nourish the uterus specifically.

Treatment

The patient received treatments 1-2 times per week from April to October for a total of 24 treatments until she successfully conceived. She then continued to receive acupuncture for support throughout her pregnancy. Occasionally, she had to go two weeks without receiving treatments due to family circumstances, but she was as compliant as she could be. Treatments prioritized directing Qi and Blood to the uterus by using moxibustion at Zigong “the palace of the child” and Ren-4 Guanyuan “Gate of Origin”. Other points were needled depending on the needs presenting that day. Additional points were from Miriam Lee’s protocol and Kidney 3 to encourage Kidney yin, yang, and jing. The patient was encouraged to keep track of her cycle although she never charted her BBT. One indicator that we tracked was the change in the patient’s cycle length.

Outcome/Prognosis

Initially, the prognosis for this case was not great. The patient had many challenges to overcome such as her age, her life stressors, and her pre-existing health history. However, she was able to conceive naturally the first time at the age of 37 indicating that her body was capable of conceiving at an advanced age. When the patient mentioned that her menses was previously 28 days long before her first child and that it has maintained at a regular 25-day cycle since its return indicated to me that her Qi and Blood were maintaining a regular cycle but that the cycle was somehow insufficient potentially because her Qi and Blood never fully recovered from pregnancy, birthing, cesarean section (a major surgery), and nursing- all of which extremely deplete Qi, Blood, and Essence in addition to the constant ongoing stressors required by her daily life.

My theory and hope was that if acupuncture and Chinese medicine could regulate and lengthen her menstruation back to a 28 day cycle, it would be an indication of her Qi, Blood, and Essence re-establishing normalcy and that she would be able to conceive and hold a pregnancy. The patient did not want to begin Chinese herbs immediately because of costs so we began with acupuncture and moxibustion first. Her menstruation was at a 28-day cycle after four weeks of twice per week treatments. She remained at 28-days there after and successfully conceived at six months so her outcome was extremely good. Genetic testing indicated that the fetus was chromosomally normal and the patient continued to have a healthy pregnancy up to the third trimester. At 35 weeks gestation, ultrasound indicated that the baby was no longer growing and the placenta was insufficient so an emergency Cesarean was performed. The baby was small but healthy and fully formed and was discharged after one week in the Neonatal Intensive Care Unit.

So although initial prognosis was not great and there were challenges and complications, the end outcome was successful. I encouraged the patient to continue acupuncture during her pregnancy because I was on my own maternity leave. She followed up with another acupuncturist twice for musculoskeletal support, but not specifically for pregnancy support. She continued seeing me once I came back from maternity leave and I continued to support her pregnancy with acupuncture and moxibustion. Treatments were spread out to every other week because of her busy schedule, and treatments continued until she delivered her baby. Post-partum care resumed a few weeks after she and her daughter were safely discharged from the hospital.

References

Chui S, Chow F, Szeto Y, Chan K, Lam C. A case series of acupuncture treatment for female infertility with some cases supplemented with Chinese medicines. Eur J Integr Med. 2014;6(3):337-341. doi:10.1016/j.eujim.2014.03.007

SH C, FC C. A Case Series on Acupuncture Treatment for Female Infertility with Some Cases Supplemented with Chinese Medicines – Follow Up Study. J Community Med Health Educ. 2016;06(01). doi:10.4172/2161-0711.1000398

Wang Y, Li Y, Chen R, Cui X, Yu J, Liu Z. Electroacupuncture for reproductive hormone levels in patients with diminished ovarian reserve: a prospective observational study. Acupuncture in Medicine. 2016;34(5):386-391. doi:10.1136/acupmed-2015-011014

Chang R, Chung P, Rosenwaks Z. Role of acupuncture in the treatment of female infertility. Fertil Steril. 2002;78(6):1149-1153. doi:10.1016/s0015-0282(02)04348-0

Liu K, Case A. Advanced Reproductive Age and Fertility. Journal of Obstetrics and Gynaecology Canada. 2011;33(11):1165-1175