Combining TCM and IVF To Improve Clinical Outcomes: Assisted Conception

www.prodseminars.
net
Combining TCM and IVF To Improve

Clinical Outcomes
Part 1 - Assisted reproduction technology and in vitro fertilization (IVF)
Part 2 - Assisted reproduction technology and traditional Chinese medicine
(TCM)
Part 3 – Treatment of the IVF patient with TCM
Part 4 – Summary of research
Assisted conception
1 Fertility drugs (drugs to induce ovulation)
2 Artificial or donor insemination
+/- Controlled ovarian stimulation and intrauterine
insemination (IUI or AI)
3 In vitro fertilisation
+/- Microsperm injection or ICSI (intracytoplasmic
sperm injection)
+/- PGD or Preimplantation genetic diagnosis

Clinical Outcomes – Jane Lyttleton 1
www.prodseminars.net
Relative success in ART clinic
IVF Statistics
The IVF programme

• the ovaries are stimulated with drugs to produce a large
number of ripe eggs
• these are collected by a needle inserted through the
vaginal wall.
• the eggs are placed in a plastic petri dish in a special
medium and mixed with a sperm sample
• embryologists monitor (or aid) the fertilisation of the
eggs and the development of any embryos over the
next few days
• at the three or five day mark one or two embryos will be
returned to the uterus
• any remaining embryos will be frozen

Ovary Stimulation
Different types of drug regimens used in IVF
• Long down regulated (agonist) cycle (± ICSI)

• Short (antagonist) cycle (± ICSI)
• Short (agonist) cycle (± ICSI)
• Natural cycle (± ICSI)
Long down regulated IVF protocol
Ovary Stimulation
Different types of drug regimens used in IVF
• Long down regulated (agonist) cycle (± ICSI)

• Short (antagonist) cycle (± ICSI)
• Short (agonist) cycle (± ICSI)
• Natural cycle (± ICSI)

IVF drugs administration (then)
IVF drugs administration (now)

• Some drugs are
injected with an
epipen under the skin
of the abdomen.
• Others are taken
orally, sprayed up the
nose or inserted into
the vagina.
Different kinds of IVF drugs

Brand names of IVF medications
• FSH – stimulates follicles to grow
Gonal-F, Puregon, Follistim, Bravelle, Menopur, Repronex, Elonva – injections
• GnRH Agonist – blocks pituitary from producing FSH or LH, after initial flare of
these hormones.
Lupron, Lucrin, Buserelin – injections
Synarel – nasal spray
• GnRH Antagonist – blocks pituitary from producing FSH or LH
Orgalutron, Cetrotide, Cetrorelix, Ganirelix – injections
• HCG – trigger to prepare oocytes for collection (except in the case of
hyperstimulation)
Pregnyl, Ovidrel, Profasi, Novarel, – injections
• Progesterone – luteal support after embryo transfer
Progesterone – injection, pessaries
Prometrium, Cyclogest – pessaries
Prometrium, Utrogestan – capsules
Crinone, Prochieve – gel
• HCG - luteal support after embryo transfer
Pregnyl – injection

Multiple follicles ripen
Oocyte collection
• A sedative is
administered.
• A local anaesthetic is
injected into the wall of
the vagina (or sometimes
a GA is used)
• A needle is placed
through the vaginal wall
into the ovary and the
fluid and egg is sucked out
of each follicle.
Egg collection guided by ultrasound.

Ultrasound view
OVUM REMOVED FROM FOLLICLE
Ovum removed from follicle

Fertilisation in a petri dish
Sperm find the egg
Fertilisation

Intra cytoplasmic sperm injection
ICSI
x 400 times magnification
Embryo cleavage

Stages of embryo division
Embryo dividing
PGD
• List of genetic diseases which can be
diagnosed is now in the hundreds.
• The major cause of pregnancy failure is
abnormal embryos
• Even normal looking embryos may have the
wrong genetic information

Embryo biopsy
Transfer of embryo
DAY 3 and DAY 5 EMBRYOS

Day 3 and Day 5 embryos
Bl ue print

Mitochondria
Mitochondrial DNA
• Maternal mitochondria play a vital role in fertilisation of

the oocyte and development of the embryo.
• The decline in mitochondrial DNA function in ageing eggs is
one expression of declining Kidney yin and yang.
ATP experiments

Generation of ATP and antioxidants in

mitochondria of mice fed Chinese herbs
H Y Leung, et al Rejuvenation research Vol 8, No 4, 2005
Generation of antioxidants in mitochondria

of mice fed Chinese herbs
Herbs used in experiments

• Ren Shen,
Radix ginseng • Dan shen,
Radix salviae
• Lu Rong,
• Chuan xiong,
Cornu cervi
Fructus cnidii
• Jiu Cai Zi, • Wu zhu yu,
Semen allii Fructus Evodiae
• Dong Chong Xia Cao, • Shan Nai,
Cordyceps Rhizoma kaempferiae

ATP production after administration of Yang

herbs cf controls
• SUO YANG 230% (123%) • XIAN MAO 149%
• TU SI ZI 222% (127%) • BA JI TIAN 142%
• ROU CONG RONG 191% • JIU CAI ZI 133%
• YIN YANG HUO 130%

• BU GU ZHI 175% (123%)
• XU DUAN 120%
• DU ZHONG 157%
• GU SUI BU 154%
WHICH YANG BOOSTING HERB?

TSZ RCR SY BGZ ZSY DZ YYH LJS XD XM BJT
JING X X x x X
BLD x X x
S HEN X
YIN X x x
YANG X X X X x X X x X X X
A/M X X X
ATP 222 191 230 175 157 130 120 149 142
Frozen embryo or cryoblastocyst

transfer

Implantation
Ovarian hyperstimulation syndrome
• Infertility Patients and Their Treatment Needs
• Comparing different infertility treatments

IVF and TCM – different approach
IVF and TCM – different techniques
IVF and TCM - different emphasis
• In the Clinic – Combining TCM and ART

TCM and IVF – points of influence
Diagnosis of the IVF patient

INFERTILITY PATIENTS AND THEIR TREATMENT

NEEDS
Where does a couple looking for fertility treatment start?
Different patients, different needs

• Couples who are having difficulty
conceiving but are not yet ready to
try IVF
• Couples who want ‘natural medicine’
• Couples for whom IVF has failed or is
not appropriate
• Couples preparing for IVF
• Combining IVF and TCM treatments
Choosing the right treatment
Cause
• of infertility Approach to treatment
•
Ma
• jor i mpediment ART
•
Mi nor i mpediment
Young woman TCM, nutri tional lifestyle program, drugs
Ol der woman ART pl us TCM
Combi nation of more than one minor TCM or ART

fa ctor
No a bnormality diagnosed TCM, nutri tional lifestyle program
IVF and TCM – different approach
TCM IVF
Thera peutic treatment Technological regimen
Ba s ic and minimally i nvasive Sophisticated a nd involved
Cl i nical personnel Cl i nical personnel
Infertility s pecialist Infertility s pecialist –drugs, surgery, pathology tests
Herbs, acupuncture Ana esthetists – general/local anaesthetics
Diet and lifestyle Nurs es – injections and blood samples
Exercise, qi gong Ra diologists – ultrasounds
Some pathology tests Embryol ogists – monitor fertilization + embryo
development
Listening, advice Couns elors – listening and advice

IVF and TCM – different techniques
TCM IVF
Hol istic Reductionist
Ti me tested New
Few s ide-effects Pos sible s ide-effects

No ri s k to mother or baby Some ri sk to mother a nd baby
demonstrated
Sl ow a cting Qui ck a cting
IVF and TCM – different emphasis
TCM IVF
Qua l ity of eggs Qua ntity of eggs
Number, s hape and vi tality of s perm ICSI
Qua l ity of endometrium Thi ckness of endometrium
Endl ess treatment va riations Few protocol variations
IN THE CLINIC – COMBINING TCM AND

ART

Different points of influence of IVF and

TCM
4 3
2
5
1
6
1 good eggs a nd s perm
2 ferti lisation
3 good embryos
4 good tubes
5 good uterine lining
6 s uccessful implantation
7 vi a ble pregnancy
How could TCM contribute to good

outcome in an IVF cycle?
• Increase ovarian response
• Increase oestrogen levels if these are low
• Enhance follicle/egg quality
• Increase follicle/egg quantity
• Improve sperm vitality
• Relieve side effects of drugs
• Increase endometrium thickness where it is too thin
• Increase implantation rates
The Effect of Chinese Herbs on Fertility

Parameters
Before After Mean
Treatment Treatment Difference
Day 1 EM 2.3 mm 2.2 mm -0.1
Day 1 FSH 10.7 9.1 -1.7
Day 11 Follicles 11.3 12.4 +1.1
Day 11 Size 11.7 mm 14.4 mm +2.8
Day 21 EM 8.3 mm 10.1 mm +1.9
Day 21 Prog 37 nmol/L 52 nmol/L +7.1
Day 21 CL size 9.4 mm 11.5 mm +2.1
Day 21 Bld flow 27 cm/sec 35 cm/sec +6

Questions we ask about IVF history
• How many stimulated IVF cycles?

• How many mature eggs collected? (Dose of FSH required?)
• How many fertilized? (with ICSI?)

• How many embryos viable on Day 3 and on Day 5?
• How many transfers of ‘fresh’ embryos overall?
• How many frozen embryos transferred overall?

• How many pregnancies, biochemical or viable?
Recap of female functional infertility

diagnoses
• Insufficient Kidney Jing
• Insufficient Kidney Yin
• Insufficient Kidney Yang
• Heart Qi stagnation
• Liver Qi stagnation
• Blood stagnation
• Phlegm-Damp accumulation
1 Insufficient Kidney jing

• Underdeveloped sexual characteristics
• Late puberty, irregular cycles, amenorrhea
• Infertility
• Constitutional weakness
• BBT shows no pattern
• Low AMH
• Ovaries not responsive to FSH drugs, estrogen levels
slow to rise
• Poor egg quality, few embryos
• Long recovery time for ovaries after IVF

2 Insufficient Kidney yin

• Long (or short) menstrual cycles
• Scanty fertile mucus
• Scanty period flow
• Restless and anxious
• BBT long or short follicular phase
• High FSH, low AMH
• Poor response to IVF drugs, low estrogen levels
• Thin endometrium
• Poor egg quality, few embryos
• Long recovery time for ovaries after drug
stimulation
3 Insufficient Kidney yang

• Short menstrual cycle, LPD
• Low libido, motivation
• Lethargy, slow metabolism
• Low back pain with period,
• Menstrual flow with tissue fragments
• BBT low or short luteal phase
• Low progesterone in mid luteal phase
• Slower embryo growth, fewer blastocysts
• Side effects in IVF cycle – fatigue, depression
• Biochemical pregnancies or early miscarriages
4 Heart qi stagnation
• Irregular or no ovulation
• Recent or historical emotional factors
• Pituitary/hypothalmus dysfunction
• Anxiety, insomnia, palpitations
• BBT unstable, especially follicular phase
• Early miscarriage
• Side effects during IVF, emotional lability, low
resilience
• Few IVF cycles

5 Liver qi stagnation
• Irregular periods
• Ovulation pain, delayed ovulation
• Premenstrual syndrome
• Fallopian tube constriction
• Prone to frustration and irritability
• BBT unstable, especially luteal phase
• Abdominal pain and swelling
• Emotional volatility, headaches during IVF
6 Blood Stagnation
• Chong channel not filled and emptied smoothly

• Endometrium uneven, clotty period flow, spotting
• Heart function (and circulation) compromised
• Polyps, fibroids, tumors, endometriosis
• Blocked tubes, ovarian cysts, pituitary tumors
• Pain
• Immune factors – implantation/placentation failure
• Poor egg quality, few embryos.
7 Phlegm Damp
• Cysts, including polycystic ovarian disease

• Blocked tubes, pituitary tumor
• Vaginal discharge, no fertile mucus
• Overweight
• Periods may be irregular, with thick or mucousy
flow
• Persistent weight gain after IVF
• Bloating and abdomen discomfort during IVF
• Large numbers of follicles during IVF (may be
immature).

TCM treatment of the IVF patient
TCM treatment of the IVF patient
• i Preparation for an IVF cycle
• ii 4 Phase treatment during the IVF cycle
• iii Ovarian Hyperstimulation Syndrome
• iv The Positive or Negative Pregnancy test
• iv Research on acupuncture and IVF
Preparing for IVF (women)
• Kidney deficiency
Herbs and acupuncture
• Egg quality
• Heart and Liver Qi stagnation

• Reducing stress
• Improving sleep
• Blood stagnation
• History endometriosis etc
• Phlegm-Damp
• Losing weight

• Kidney
deficiency
Egg quality
Preparing for IVF with herbs -

Kidney deficiency (egg quality)
Gui Shao Di Huang Tang (Angelica Peonia Rehmannia Decoction) modified
• Shu Di 12 g Radix Rehmanniae Glutinosae Conquitae

• Shan Yao 9 g Radix Dioscorea Oppositae
• Shan Zhu Yu 9 g Fructus Corni Officinalis
• Fu Ling 9g Sclerotium Poriae Cocos
• Mu Dan Pi 9g Cortex Moutan Radicis
• Ze Xie 6g Rhizoma Alismatis
• Dang Gui 9g Radix Angelicae Sinensis
• Bai Shao 9g Radix Paeoniae Lactiflorae
• Dan Shen 9g Radix Salviae Miltiorrhizae
• Sha Ren 6g Fructus seu Semen Amomi
• Tu Si Zi 9g Semen Cuscatae
• Bu Gu Zhi 9g Fructus Psoraleae
• Xiang Fu 6g Rhizoma Cyperi Rotundi
• He Huan Pi 9g Cortex Albizziae Julibrissin
• Suo Yang 6g Herba Cynomorii Songarici
• Lu Jiao Pian 6g Cornu Cervi Parvum
• Zi Shi Ying 6g Fluoritum
Preparing for IVF with acupuncture Kidney

deficiency (egg quality) Post-menstrual phase
Treatment goal Acupuncture point
To ba lance both the Ren a nd Chong vessels Ren-7, KI-5, KI-8, KI-13
a t the outset of the cycl e
To i nfluence Chong vessel a ctivi ty SP-4, ST-30
To encourage Blood production ST-36, LIV-3 a nd SP-10
To emphasize development of Ki dney Yi n KI-3, KI-5, KI-6, SP-6, BL-23, Ren-4
To i nfluence Ki dney Ji ng ST-27
To regulate Qi in the reproductive organs Ba l iao

a nd s upplement the Ki dneys

Preparing for IVF with acupuncture -

Kidney deficiency (egg quality) Ovulation phase
Treatment goal Acupuncture points
To regulate the Qi - ovaries and tubes KI-13, KI-14, SP-13, ST-28, ST-29, Zi gong
To move the Qi in the Liver cha nnel LIV-3 a nd LIV-5
To promote ovulation by regulating Qi /Blood KI-5 a nd KI-8
To enhance K function; s tabilize emotions KI-4
To cl ear s ecretions from the fallopian tubes GB-26
To ca l m the mind; cl ear excess s ecretions SP-5
To promote ci rculation of Blood at ovulation SP-8
To promote Sp as a n intermediary between SP-6
the Ht a nd K (the Bao vessel/ Bao channel)
To ca l m the spirit, i nfluence the Bao vessel HE-5 a nd PC-5
To further ca lm the mi nd HE-7 a nd PC-6, Yi ntang
To regulate the Ht Qi , cl ear Heat i n the Blood PC-4

Kidney deficiency (egg quality) Luteal phase
Treatment goal (Boost K yang by reinforcing Acupuncture point

K yin)
To rei nforce Kidney Ya ng Ren-2 1st week
To rei nforce Kidney Yi n and Ya ng Ren-4 1st week
To regulate Qi /maintain flexibility i n the Ren-5 1st week
uteri ne walls
To regulate the activity of the Chong and Ren Ren-7
vessels
To ca l m the mind if there is a gitation Ren-15, Yin Tang, Du 20, Pc 6
To encourage development of Ki dney Ya ng by KI-3, KI-6
i nvi gorating Ki dney Yin BL-23 1st week

Treatment goal (boost Kidney Yang by Acupuncture point

promoting Qi)
To i nvi gorate the Spleen a nd Stomach Ren-12, Ren-6, ST-36, ST-25, BL-20, SP-
Qi 6 1st week
To s upport the development of Ki dney KI-3,

Ya ng Ren-4 1st week, BL-23 1st week
To regulate Qi in the Ren channel a nd Ren-5 1st week

a bdomen


Treatment goal (boost Kidney Yang by Acupuncture point
nourishing Blood)
To i nfluence Blood formation BL-17,

SP-10 1st week
To enhance Blood formation vi a the KI-5
Ki dney Ya ng
To s upport the role of the Stomach and ST-36, Ren-12
Spl een in making a nd distributing Blood SP-6 1st week
To s upport Ki dney Yi n a nd Ya ng and Ren 4 1st week
i nvi gorate Qi and Blood of the Zang
• Heart and
Liver Qi
stagnation
• Reducing stress
• Improving sleep
Preparing for IVF with herbs - Heart and

Liver Qi stagnation (treat sleep/stress)
Gui Shao Di Huang Tang (Angelica Peonia Rehmannia Decoction) with Xiao Yao San
(Bupleurum and Tangkuei Powder) and Gan Mai Da Zao Tang (Licorice, Wheat, and Jujube
Decoction) modified

• Shan Yao 9 g Radix Dioscorea Oppositae
• Dang Gui 9 g Radix Angelicae Sinensis
• Bai Shao 9 g Radix Paeoniae Lactiflorae
• Dan Shen 9 g Radix Salviae Miltiorrhizae
• Fu Ling 9 g Sclerotium Poriae Cocos
• Mu Dan Pi 9 g Cortex Moutan Radicis
• Ze Xie 9 g Rhizoma Alismatis
• Sha Ren 3 g Fructus seu Semen Amomi
• Tu Si Zi 9 g Semen Cuscatae
• Xiang Fu 6 g Rhizoma Cyperi Rotundi
• He Huan Pi 9 g Cortex Albizziae Julibrissin
• Chai Hu 9 g Radix Bupleuri
• Fu Xiao Mai 6 g Semen Tritici Aestivi Levis
• Da Zao 6 pieces Fructus Zizyphi Jujuba
• Gan Cao 6 g Radix Glychyrrhizae Uralensis

Preparing for IVF with acupuncture

Heart and Liver Qi stagnation (treat sleep/stress)
To regulate Li ver Qi Al l Li ver channel points
To a ddress Liver Bl ood deficiency LIV-3 a nd LIV-8
To regulate Li ver-Fire (irritability and LIV-2
a nger)
To regulate Qi in the uterus Choos e from LIV-4, LIV-5, LIV-9, LIV-11
To rel ieve emotional stress LIV-5
To ca l m the mind and regulate Li ver Qi PC-6, PC-7 a nd PC-5
i n the upper body
To pa ci fy the spirit, enhance sleep HE-5 a nd HE-7, Yin Tang
To regulate Qi in the Ren a nd Li ver Ren-3
cha nnels
• Blood
stagnation
• History
endometriosis etc

Blood stagnation 1 (Hx Endometr etc)
Tao Hong Si Wu tang (Persica Carthamus Four Substances Decoction) modified

• Chi Shao 9g Radix Paeoniae Rubra
• Chuan Xiong 6 g Radix Ligustici Wallichii
• Tao Ren 9 g Semen Persicae
• Hong Hua 9g Flos Carthami Tinctorii
• Gui Zhi 3g Ramulus Cinnamoni Cassiae
• Shan Zha 6g Fructus Crataegi
• Pu Huang 9 g Pollen Typhae
• Wu Ling Zhi 9 g Excrementum Trogopterori
• Yan Hu Suo 12 g Rhizoma Corydalis Yanhusuo
• Xu Duan 9g Radix Dipsaci
• Chuan Niu Xi 6 g Radix Cyathulae


Blood Stagnation 2 (Hx Endometr etc)
G u i S hao D i H uang t ang ( Angelica P eonia R ehmannia D ecoction)and T ao H ong S i W u t ang ( Persica C arthamus
F o u r S ubstances D ecoction) m odified
• Shu Di 9 g Rehmanniae Glutinosae Conquitae
• Shan Yao 9 g Dioscorea Oppositae
• Mu Dan Pi 9 g Cortex Moutan Radicis
• Ze Xie 9 g Rhizoma Alismatis
• Xiang Fu 6 g Rhizoma Cyperi Rotundi
• Tao Ren 9 g Semen Persicae
• Hong Hua 9 g Flos Carthami Tinctorii
• Pu Huang 9 g Pollen Typhae
• Wu Ling Zhi 9 g Excrementum Trogopterori
Preparing for IVF with acupuncture - Blood

Stagnation (Hx Endometr etc)
To regulate Blood i n the Uterus LIV-8, LIV-5, KI-14, SP-6, SP-8, SP-10
To regulate Qi and Blood in the abdomen ST-28 a nd ST-29, Ah Shi points
To regulate Blood i n the Ki dney a nd Ren KI-5

cha nnels
To hel p resolve Blood stagnation by Ba l iao
s trongly regulating Qi i n the l ocal area
To s upport movement of Blood Bl 17
To a l leviate menstrual pain Pc 5
• Phlegm-
Damp
• Losing weight


Phlegm-Damp (weight loss)
Gui Shao Di Huang Tang (Angelica Peonia Rehmannia Decocotion) plus Jian Gu Tang (Strengthen
and Consolidate Decoction) modified
• Nu Zhen Zi 9g Fructus Ligustri Lucidi

• Han Lian Cao 9g Herba Ecliptae Prostratae
• Shan Yao 9g Dioscorea Oppositae
• Shan Zhu Yu 9g Fructus Corni Officinalis
• Ji Xue Teng 9g Radix et Caulis Jixueteng
• Yi Yi Ren 15 g Semen Coicis Lachryma-jobi
• Dang Shen 9g Radix Codonopsis Pilulosae
• Bai Zhu 9g Rhizoma Atractylodis Macrocephalae
• Ba Ji Tian 9g Radix Morindae Officinalis
• Yin Yang Huo 9g Herba Epimedii
• Zao Jiao Ci 6g Spina Gleditsiae Sinensis
• Dan Nan Xing 6g Rhizoma Arisaematis
Preparing for IVF with acupuncture –

Phlegm Damp (weight loss)
Treatment goal Acupuncture point
To tra nsform and distribute accumulation of Ren-9

fl ui d in the abdomen, s pecifically the uterus
To res olve Damp by strengthening K Ya ng Ren-3 a nd Ren-6, K-7
To res olve Phlegm-Damp in Dai Cha nnel GB-26, GB-27 a nd GB-28
To regulate Damp in the pelvic cavity by BL-22 a nd BL-28

promoting removal of fl uids via the bladder
To move fl uids by moving Qi i n the uterus BL-32
To move fl uids by moving Blood i n the uterus St 29 (moxa )
To s upport the Spleen in its action of SP-9, SP-6 a nd SP -5

tra ns forming fluids a nd Damp
Preparing for IVF with herbs (men)
Bu Shen Yi Jing fang (Supplement the Kidneys Benefit the Jing Formula) modified
• Fu Pen Zi 12 g Fructus Rubi Chingii
• Nu Zhen Zi 9 g Fructus Ligustri Lucidi
• Gou Qi Zi 9 g Fructus Lycii Chinensis
• He Shou Wu 12 g Radix Polygoni Multiflori
• Sheng Di 9g Radix Rehmanniae Glutinosae
• Dang Shen 9g Radix Codonopsis Pilulosae
• Huang Qi 12 g Radix Astragali
• Yin Yang Huo 9 g Herba Epimedii

Preparing for IVF acupuncture

(men)
To reinforce Kidney Jing, Yin and Yang Ren-4, K-6, K-3, BL-23, BL-52, DU-4
To resolve Blood or Qi stagnation ST-30, LIV-5, 8, SP-10, PC-6, BL-32, 33
To clear Damp Heat CO-4, CO-11, GB-41, GB-27, LIV-8
To regulate Liver Qi, relieve stress LIV-3, CO-4
To reinforce Spleen/Stomach Qi Ren-6, SP-6, ST-36
To calm shen, relieve insomnia HT-7, PC-6, DU-20
To increase blood flow in the testicles ST-29, SP-6
Summary of influences on sperm quality,

follicular microenvironment and egg quality in
preparation for IVF
• Increase blood supply (oxygen and nutrients) to the testicles with
acupuncture
• Increase blood supply (oxygen and nutrients) to the follicles with
acupuncture
• Improve ovarian function by regulating hormone levels (e.g., LH,
testosterone, insulin) with acupuncture
• Reduce stress hormones associated with reduced IVF success with
acupuncture
• Increase oocyte mitochondrial ATP output with certain Chinese herbs
• Enhance follicle antioxidant defenses with certain Chinese herbs
• Improve follicle environment by reducing inflammatory cytokines with
certain Chinese herbs.
Treatment During the IVF Cycle


with herbs?

with acupuncture?
4-Phase TCM treatment during the IVF

cycle
• Phase 1 (menstrual period) Day 1–3

• Phase 2 (follicle development) Day 4 to approx. Day 11
• Phase 3 (approx. Day 11–14, follicle maturation, trigger injection + egg
collection)
The male partner ’s role
• Phase 4a (Day 14–Day 16/19, from egg collection to embryo transfer)
After egg collection
The day of embryo transfer
• Phase 4b (day after embryo transfer until pregnancy test or period,
implantation)

Phase 1 acupuncture
Day 1–3 (menstrual period)
Drugs: FSH ± GnRH agonist
To open the uterus a nd encourage downward movement CO-4 wi th SP-6
a nd a smooth and thorough discharge of the menstrual fl ow
To moderate this a ction a nd hold the Qi Ren-6
To trea t a ll aspects of the Blood, both i ts movement a nd i ts SP-10
s upplementation a nd control heavy bl eeding i f there i s Heat
To remove obstructions to Blood flow SP-8
To move Bl ood i n the Chong channel KI-14
To regulate the Qi in the uterus and moderate the Ti tuo
des cending action of SP-6
To regulate Qi in the lower Jiao BL-25 a nd BL-30
To regulate Qi specifically i n the Uterus BL-32, Shi qizhui
To regulate Qi , particularly i f there is pain i n the sacrum Ba l iao (BL-31–34)
To ma ke Blood flow s moothly, relieve pain, calm the mind PC-5
Phase 1 Herbs
Day 1–3 (menstrual period)
Drugs: FSH ± GnRH agonist
Tao Hong Si Wu tang (Persica Carthamus Four Substances decoction) modified (for use during IVF
cycle in restricted circumstances)

• Chuan Xiong 6 g Radix Ligustici Wallichii
• Tao Ren 6g Semen Persicae
• Yi Mu Cao 9 g Herba Leonuri Heterophylli
• Ji Xue Teng 12 g Radix et Caulis Jixueteng
• Shan Zha 6 g Fructus Crataegi
• Chuan Niu Xi 6 g Radix Cyathulae
Phase 2 Acupuncture
Day 4 to approx. Day 11 (follicle development)
Drugs: FSH ± GnRH agonist or antagonist

To regulate Ren a nd Chong vessels Ren-7, KI-5, KI-8, KI-13
To encourage Blood production (build ST-36, LIV-3, BL-17, BL-20, SP-10
endometrium)
To s upport Ki dney Yi n a nd Ji ng KI-3, KI-5, KI-6, SP-6, BL-23, Ren-4, ST-27
To i ncrease Blood fl ow to the uterus BL-28, BL-23, SP-6, BL-57, SP-4, PC-6, ST-
30
To i ncrease Blood fl ow to the ovaries ST-28, ST-29, SP-6, SP-9
To regulate Qi around the ovaries ST-28, ST-29, Zi gong, LIV-5, LIV-8
To s ta bilize Shen Yi n Ta ng, HT-7, HT-4, Ren-14
To trea t headaches, depression, irritability CO-4, LIV-3, YT, GB-20, DU-20

Phase 2 Herbs
Day 4 to approx. Day 11 (follicle development)
Drugs: FSH ± GnRH agonist or antagonist
Gui Shao Di Huang tang (Angelica Peonia Rehmannia Decoction) modified
•
• Shan Zhu Yu 9g Fructus Corni Officinalis
• Shan Yao 9g Radix Dioscorea Oppositae
• Dang Gu i 9g Radix Angelicae Sinensis
• Fu Ling 9g Sclerotium Poriae Cocos
• Wu Yao 3g Radix Linderae Strychnifoliae
• Yin Yang Huo 6 g Herba Epimedii
• Lu Jiao Pian 6g Cornu Cervi Parvum
• Suan Zao Ren 9 g Semen Ziziphi Spinosae
Phase 3 Acupuncture
Day 11–14 approx, follicle maturation, trigger injection + egg collection
Drugs: FSH + GnRH agonist or antagonist + hCG trigger
To s upport Ki dneys a nd promote growth of the Ren-4, KI-6, KI-13, K-14
fol licles/eggs (days before tri gger i njection)
To boost Ki dney Ya ng and promote final maturation KI-5, KI-8, Zi gong, SP-6
of fol licles/eggs (day of tri gger i njection)
To enhance Kidney function a nd stabilize emotions KI-4
To regulate Qi , relieve a bdomen distension (lower), Ren-6, ST-28, ST-29, SP-6, LIV-5, SP-13,
promote ci rculation to ovaries Ah Shi points
To regulate Qi , relieve a bdomen distension (upper) GB-34, Ren-12, LIV-5, LIV-8, REN-9
To regulate Li ver Qi , relieve i rritability, depression LIV-3, CO-4
or hea daches
To ca l m Li ver wind, relieve dizziness LIV-8, CO-11
To cl ear Heat, relieve rashes SP-10, CO-11
To regulate the Heart Qi , calm the mind, relieve PC-4, 5 or 6, HE-5, 7, Yi ntang
i ns omnia
Phase 3 Herbs
Day 11–14 approx, follicle maturation, trigger injection + egg collection
Drugs: FSH + GnRH agonist or antagonist + hCG trigger
Bu Shen Cu Pai Luan Tang (Reinforce Kidney and Ovulation Formula) modified

• Rou Cong Rong 9 g Herba Cistanches
• Suo Yang 6g Herba Cynomorii Songarici
• Xiang Fu cu 12 g Rhizoma Cyperi Rotundi
• Qing Pi 3 g Pericarpium Citri Reticulatae Viride
• Ju He 3 g Semen Citri Reticulatae
• Li Zhe He 3g Semen Litchi
• Wu Yao 3g Radix Linderae Strychnifoliae

Male partners role

(Phase 3 day of sperm donation)

Rei nforce K Qi Ren-4, K-3, K-6, LU-7
Forti fy Ya ng Ren-4 a nd 6 with moxa (if there is
Col d), DU-20
Rei nforce a nd regulate Qi and Blood ST-29, SP-6, SP-10, LIV-5, 8, PC-6
s upply
Reduce a nxiety YT, LIV-3, CO-4 (20 mi n only)
Cl ea r Damp in Lower Ji ao, if necessary GB-41, TH-5
Phase 4a Acupuncture
Day 14–Day 16/19, from egg collection to embryo transfer
Drugs: progesterone support (pessaries, injections, gel) or HCG injections

To regulate Qi and Blood in the Ren a nd Ren-7, Ren-3, K-14, PC-6, SP-4
Chong cha nnels
To regulate Li ver Qi , reduce s welling, LIV-5, LIV-4, GB-34, GB-27 or Ah
a l leviate pain Shi points on the a bdomen
To regulate Blood, cl ear Bl ood stasis, SP-10, SP-8, ST-29, ST-30, BL-57,
promote ci rculation to the endometrium BL-32
To boost Ki dney Ya ng Ren-4, Ren-6, K-13, K-6, K-3, BL-23
To ca l m the Shen HT-7, YT, DU-20
Phase 4a Herbs
Day 14–Day 16/19, from egg collection to embryo transfer
Drugs: progesterone support (pessaries, injections, gel) or hCG injections
Bu Shen Cu Pai Luan (Reinforce Kidney Ovulation formula) modified

• Chi Shao 6g Radix Paeoniae Rubra
• Hong Hua 3g Flos Carthami Tinctorii
• San Qi 3g Radix Pseudoginseng
• Shu Di 6g Rehmanniae Glutinosae Conquitae
• Xu Duan 12 g Radix Dipsaci

Phase 4a cont; Acupuncture

– the day of embryo transfer

To regulate Li ver Qi , reduce uterine LIV-3, GB-34, CO-4
cra mping
To regulate Blood, cl ear s tasis, promote SP-10, SP-8, ST-29
ci rcul ation to the endometrium
To promote production of Blood and Qi ST-36, SP-6
To boost Ki dney Ya ng Ren-4, Ren-6, K-6, K-3
To regulate the a ctivity of the Chong Ren-7
a nd Ren vessels
To ca l m the Shen HT-7, PC-6, YT, DU-20
Phase 4b Acupuncture
(from day after embryo transfer until pregnancy test or period, implantation)
Drugs: progesterone pessaries, injections or gel or hCG injections

To boost Ki dney ya ng K-6, K-5
To regulate Li ver Qi , reduce uterine cra mping GB-34, LIV-3, LIV-4, LIV-5, LIV-9, LIV-11
To regulate Blood i n the Li ver, Ki dney a nd Ren LIV-8, LIV-3, KI-5
cha nnels a nd a ddress Li ver Blood deficiency
To i nvi gorate the Spleen a nd Stomach a nd ST-36, BL-17, BL-20, BL-21
promote production of Blood and Qi
To ca l m the Shen, safeguard the Bao Luo YT, DU-20, Ren-15, HE-5, HE-7, K-9
ves s el
To rel ieve stress a nd regulate Li ver Qi i n the LIV-5, PC-6, PC-7, PC-5
upper body
Phase 4b Herbs
(from day after embryo transfer until pregnancy test or period,
implantation)
Drugs: progesterone pessaries, injections or gel or hCG injections
You Gui wan (Restore the Right Kidney Pill) plus Yu Lin Zhu (Fertility Pearls) modified
• Bai Zhu 12 g Rhizoma Atractylodis Macrocephalae

• Shu Di 9g Radix Rehmanniae Glutinosae Conquitae
• Shan Yao 9 g Dioscorea Oppositae
• Du Zhong 6 g Cortex Eucommiae Ulmoidis
• Ba Ji Tian 9 g Radix Morindae Officinalis
• Gan Cao 3g Radix Glychyrrhizae Uralensis

IVF side effects

(and TCM treatment)
• Headaches • Liver qi stagnation
• Abdomen pain and distension• Heart/shen disturbance
• Nausea • Liver Wind
• Irritability and moodiness
• Heat in the Blood
• Insomnia, agitation
• Fatigue • Blood stagnation
• Difficulty breathing and • Phlegm Damp
dizziness accumulation
• Skin rash
• Blood clotting
• Weight gain
OVARIAN HYPER-STIMULATION SYNDROME -

acupuncture

To regulate water passages a nd a lleviate Ren-9, Ren-5, ST-28, K-5, SP-9
pa i n a nd distention of abdomen
To promote removal of fl uids via the BL-22, BL-28
bl a dder
To des cend rebellion, alleviate s hortness SJ-10, LIV-4, CO-6, Ren-17
of brea th, ascites
To res olve accumulations a nd s welling via GB-26, GB-27, GB-28
the Da i Channel
To regulate Qi and Blood, clear s tasis K-14, BL-32
To regulate water passages a nd descend LU-7, LU-1
Lung Qi
To regulate water passages a nd benefit K-7
Ki dney
OVARIAN HYPER-STIMULATION SYNDROME - Herbs
To You Gui wan (Restore the Right Kidney Pill) plus Yu Lin Zhu (Fertility Pearls)
modified (see Phase 4b)
Add
• Hua ng qi (Radix As tragali) 20 - 30g,
• Zhu Li ng (Polyporus) 15g
• Ze Xi e (Rhizoma Alismatis) 15g,
a nd i ncrease Fu Li ng (Poria) to 15g.
If there is marked stasis, and embryo tra nsfer has been postponed for another ti me,
• Da n Shen (Radix Salviae Mi ltiorrhizae) 15 – 20g, ca n be a dded.

THE POSITIVE PREGNANCY TEST

– acupuncture
early stage of pregnancy after an IVF cycle
To s ta bilize Shen YT, DU-20, PC-6, HT-7, K-4, K-9
To s upport Ki dney Qi K-6
To s upport Spleen Qi ST-36
To a l leviate residual a bdominal LIV-5, GB-34

di s comfort or ova rian swelling
THE POSITIVE PREGNANCY TEST –

Herbs
early stage of pregnancy after an IVF cycle
Yishen Gutai Tang (Nourish Kidney and Protect Fetus) modified
• Du Zhong 15g Cortex Eucommiae Ulmoidis
• Sang Ji Sheng 15 g Ramulus Sangjisheng
• Huang Qin 9 g Radix Scutellariae Baicalensis
• Gou Qi Zi 12 g Fructus Lycii Chinensis
• Dang Shen 12 g Radix Codonopsis Pilulosae
• Da Zao 3 pieces Fructus Zizyphi Jujuba
• He Shou Wu 12 g Radix Polygoni Multiflori
If there is any bleeding add

• E Jiao 15g (Gelatinum Asini)
• Zhu Ma Gen (Radix Boehmeriae ) 9g
THE NEGATIVE PREGNANCY TEST

- acupuncture

To re-establish Chong channel function SP-4, PC-6
To regulate Chong and Ren channels Ren-3, Ren-7
To a l leviate grief and sadness, benefit LU-3, HT-7, HT-4, YT
s l eep
If bl eeding after IVF cycl e persists for SP-10, K-3
l onger than usual
To rel ieve abdominal bloating or Ren-6, ST-28, LIV-5, SP-6
di s comfort
To s trengthen the Ki dney Qi Ren-4, K-6

Part 4
RESEARCH IN ACUPUNCTURE AND
IVF
Acupuncture and embryo transfer studies Effect of acupuncture on pregnancy rate

AUTHORS and REFERENCES
Paulus W et al, Fertil Steril 2002 Vol 77, pg 721-724 +ve

Smith C et al, Fertil Steril 2006 Vol 85, pg 1352-1358 +ve
Westergaard L et al, Fertil Steril 2006 Vol 85, pg 1341-1346 +ve

Dieterle S et al, Fertil Steril 2006 Vol 85, pg 1347-1351 +ve
Benson M. R. et al, Fertil Steril 2006 Vol. 86, Suppl 1, pg S135 +ve
Udoff L. C. et al, Fertil Steril , 2006 Vol 86, Suppl 1, pg S145 +ve
Teshima D. R. K. et al, Fertil Steril 2007 Vol 88, Suppl 1, pg S330 +ve
Magarelli P, D Cridennda. Fertil Steril 2004 Vol 81, Suppl 3, pg S20 +ve
Quintero R et al, Fertil Steril 2004 Vol 81 Suppl 3 pg S11-12 +ve
Dalton-Brewer N et al, Hum Fert 2010 Vol 12 No 4 212 - 255 +ve
Zhang M et al,Chin Acup and Moxabustion 2003, Jan 23 (1): 3 - 5 +ve
Balk J et al, Compl Therapies in Clinical Practice 2010,16,154–157 +ve
Kong S. Hughes A Medical Acupuncture 2009 21(3) p179-182 +ve
Chen J et al Zhongguo Zhen Jiu. 2009 Oct;29(10):775-9 +ve

Zhang R et al, Fertil Steril 2011, 96, 4 Pg 912-916 +ve
Domar A et al, Fertil Steril 2006 Vol. 86 Suppl 2, pg S379 =
Domar A et al, Fertil Steril 2009 Vol 91 pg 723 - 6 =

Fratterelli JL et al Fertil Steril 2008 Vol 90 Suppl 1, pg S105 =
So et al, Hum Reprod. 2009 Feb;24(2):341-8. =

Andersen D et al, Reprod BioMedicine Online, 2010, 21, 3, 366-372 =
Moy I et al Fertil Steril. 2011;95:583-587 =
Craig L. B. et al Fertil Steril 2007 Vol. 88, Suppl 1, pg S40 -ve
Points used in clinical trials investigating effect of

acupuncture at time of embryo transfer
Points used before Embryo Transfer Points used after Embryo Transfer
• Pc 6, Sp 8, Liv 3, Du 20, St 29 • St 36, Sp 6, Co 4, Sp 10
• Ear points; shenmen, zhigong • Ear points; shenmen, zhigong
(uterus), neifenmi (endocrine), (uterus) neifenmi (endocrine)
naodian (sympathetic or brain) (variations/additions Ren 4, Ren 6, St
(variations/additions Zigong, Sp 10, 29, Pc 6, Sp 8, K 3, Bl 23, Ear pts
Ren 6) pizhixia)

1st Meta analysis; IVF and acupuncture

Clinical Ongoing Live birth
pregnancy pregnancy
Odds ratio 1.65 1.87 1.91
95% 1.27 - 2.14 1.40 - 2.49 1.39 - 2.64

confidence
interval
Number needed 10 (7-17) 9 (6 - 15) 9 (6 - 17)
to treat
No of trials 7 5 4
Manheimer E et al. BMJ 2008;336:545-549
4 meta analyses
1 Effects of acupuncture on rates of pregnancy and live birth among women
undergoing in vitro fertilisation: systematic review and meta-analysis.
Manheimer E et al. BMJ 2008;336 pg 545-549
2 Acupuncture and Assisted Conception

Cheong Y et al, Cochrane Database of Systematic Reviews 2008 Issue 4
3 Acupuncture and Assisted Conception

Cheong Y et al Cochrane Database of Systematic Reviews 2009 Issue 1
4 A Sy stematic Review and Meta -analysis of the effect of Acupuncture

on Outcome of in Vitro Fertilisation Treatment
El-Toukhy T et al BJOG 2008 115 (10); 1203 -13
Most recent meta analysis
Outcome clinical pregnancy
Outcome live birth

Acupuncture points shown in clinical

trials to affect blood flow to uterus
• Bl 28 Bl 23 • Liv3, Sp 6, St 28, zigong, Ren 6, Ren 4
• High frequency (100 Hz) pulses of 0.5 ms • Low frequency (10Hz) for 30 minutes.
duration,
• (Ming Ho et al 2009 - 4 treatments, women
• Bl 57 Sp 6 taking FSH and GnRH antagonist drugs,
• Low frequency (2Hz) pulses of 0.5ms duration. showed reduction of uterine artery
• (Stener Victorin et al 1996 - 8 treatments, impedance)
women taking GnRH agonists, showed reduction
of uterine artery impedance)
• Pc 6, Sp 8, Liv 3, Du 20, St 29
• (So et al 2009 1 treatment, before embryo transfer, no electro-stimulation, showed reduced vascularity of endometrium)
• St 28 and Sp 6.
• Points in abdominal and the hindlimb muscles of rats, corresponding to above points
• Stener-Victorin E et al 2003, Low-frequency 2 Hz EA at 3 and 6 mA elicited significant increases in ovarian blood flow.
•
•
Research conclusion?
The way of the future


Combining TCM and IVF To Improve Clinical Outcomes: Assisted Conception

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Combining TCM and IVF To Improve

Combining TCM and IVF To Improve

Relative success in ART clinic

The IVF programme

Combining TCM and IVF To Improve

Different types of drug regimens used in IVF

• Long down regulated (agonist) cycle (± ICSI)

Long down regulated IVF protocol

Different types of drug regimens used in IVF

• Long down regulated (agonist) cycle (± ICSI)

Combining TCM and IVF To Improve

IVF drugs administration (then)

IVF drugs administration (now)

Different kinds of IVF drugs

Combining TCM and IVF To Improve

Multiple follicles ripen

Egg collection guided by ultrasound.

Combining TCM and IVF To Improve

OVUM REMOVED FROM FOLLICLE

Ovum removed from follicle

Combining TCM and IVF To Improve

Fertilisation in a petri dish

Sperm find the egg

Combining TCM and IVF To Improve

Intra cytoplasmic sperm injection

Combining TCM and IVF To Improve

Stages of embryo division

Combining TCM and IVF To Improve

DAY 3 and DAY 5 EMBRYOS

Combining TCM and IVF To Improve

Day 3 and Day 5 embryos

Combining TCM and IVF To Improve

• Maternal mitochondria play a vital role in fertilisation of

Combining TCM and IVF To Improve

Generation of ATP and antioxidants in

H Y Leung, et al Rejuvenation research Vol 8, No 4, 2005

Generation of antioxidants in mitochondria

Herbs used in experiments

Combining TCM and IVF To Improve

ATP production after administration of Yang

• SUO YANG 230% (123%) • XIAN MAO 149%

• TU SI ZI 222% (127%) • BA JI TIAN 142%

• ROU CONG RONG 191% • JIU CAI ZI 133%

• YIN YANG HUO 130%

WHICH YANG BOOSTING HERB?

Frozen embryo or cryoblastocyst

Combining TCM and IVF To Improve

Ovarian hyperstimulation syndrome

• Infertility Patients and Their Treatment Needs

• Comparing different infertility treatments

• In the Clinic – Combining TCM and ART

Combining TCM and IVF To Improve

INFERTILITY PATIENTS AND THEIR TREATMENT

Different patients, different needs

Choosing the right treatment

Combi nation of more than one minor TCM or ART

No a bnormality diagnosed TCM, nutri tional lifestyle program

IVF and TCM – different approach

Combining TCM and IVF To Improve

IVF and TCM – different techniques

Few s ide-effects Pos sible s ide-effects

IVF and TCM – different emphasis