Assisted reproduction technology and traditional Chinese medicine

Infertility Patients and their Treatment Needs

Where does a couple looking for fertility treatment start?

Many patients will make their first appointment in the TCM (traditional Chinese medicine) clinic, based on their philosophical preferences and recommendations made by friends or the family doctor. Some patients will be wondering which is the correct approach for them. Is ART (assisted reproduction technology) or TCM better – For different types of patients? – For different types of infertility? – For different stages of infertility treatment? The answer is Yes on all counts and the advice given by the primary practitioner needs to be thoroughly informed (see Box 10.1).

The sort of treatments appropriate for patients who fall into the first four categories in Box 10.1 are those that we have discussed in the previous chapters. Patients who have had bad reactions to the drugs prescribed in ART clinics may need some rehabilitation, both physiologic in correcting the menstrual cycle, and emotional. Where there is Kidney weakness (which is the case for most functional infertility), Chong and Ren vessel function is vulnerable to disruption. What happens during an IVF cycle causes massive disruption to the natural function of the Chong and Ren vessels.

Box 10.1 Different patients, different needs

Couples ^a who are having difficulty conceiving but are not yet ready to try IVF

Some of these patients become pregnant with the help of TCM, some move onto the ART clinic after a certain time.

Couples who want ‘natural medicine’

Some couples who consult a TCM doctor do so because they have a philosophical attachment to the use of natural medicines and a fear of doctors, surgery, and drugs. In some cases, these couples have made a choice not to use ART because they are concerned about the possible risks to the baby. Many of these couples are committed to maintaining their own good health and are often well educated and informed. If their infertility is ‘unexplained’, then often TCM will uncover a possible cause, and because these patients are generally healthy, compliant and motivated, the results are often good. However, in some of these cases (e.g., tubal blockage or very low sperm count), it is just not in the best interests of the couple to rely on TCM when their only real hope of conception is to try and overcome their objections or fear and embrace sensibly the help modern medicine can offer. Often hearing such advice from a trusted TCM doctor – on the other side of the fence, so to speak – can help to break down fears, and referral to a compassionate specialist in ART is the next step.

Couples for whom IVF has failed or is not appropriate

This group constitutes a large proportion of patients seeking Chinese medicine treatment and includes women who:

• have completed three or more IVF cycles without success (most IVF successes are within the first 3 cycles)

• showed no response or a paradoxical response to the drugs used during IVF

• are over 43 (IVF success is rare in this age group, unless donor eggs are used).

Couples preparing for IVF

Some couples who are planning to use IVF, or to return to IVF after a break, wish to prepare themselves (and their gametes) by using a therapy that enhances their health in the hope of increasing chance of success.

Combining treatments

The last group of couples who seek TCM treatment for infertility are those who wish to try everything, usually all together!

^a The term ‘couple’ here includes heterosexual and lesbian couples but also applies to single women using sperm donors.

Where Kidney deficiency in the woman undergoing IVF is significant (this is the woman who is older, or who ovulates irregularly and poorly, who may have been trying to become pregnant for a long time), high doses of follicle stimulating drugs will be required to get a minimal response. Such high doses or repeated use can jeopardize what was already fragile ovary function, sometimes catastrophically. In the worst case scenario, menstrual cycles do not recover and a (peri)-menopausal pattern sets in.

For women in this category (men’s Kidney energy is not challenged directly by IVF), the aim of treatment is to restore Kidney Yin and Yang function in a regular cyclical fashion. Applying the principles outlined in Chapter 4 is the correct approach; however, be prepared for a longer than usual period of Kidney Yin reinforcement. In addition, Liver and Heart Qi stagnation will always need addressing after a failed IVF cycle – in some women more than others.

It is the last group mentioned in Box 10.1, those couples who wish to try everything, who present some unique challenges in the clinic. The combining of Chinese medical therapy with IVF requires careful thought – and like all the ART techniques of the last few decades, some experimentation. This is an area ripe for research – already underway in many countries (see below).

Such a combination throws TCM into a cutting-edge modern medical arena, but the beauty of this oldest of all existing medical systems is that it is universally applicable and unceasingly flexible. Even if the patient is taking drugs that stop the pituitary gland dead in its tracks; is having surgical procedures to remove artificially ripened gametes from their glandular homes; or is experiencing intense emotional stress, the doctor of Chinese medicine can still make a diagnosis incorporating all those factors and their effect on the body and mind, and can prescribe treatment which not only focuses on the particular imbalance but may also work with the medical interventions to make their results better and their side-effects less.

Referral to ART clinics is sometimes made too early and sometimes inappropriately. Some couples spend a lot of money and take unnecessary risks using drastic measures, when simple alternative methods could have been just as effective if they had been well enough informed to pursue them. Remember our patient in Chapter 1 with sharp corners? On the other hand, some patients pursue ‘natural’ therapies for too long, when their main or only chance of success is to use IVF.

We can put couples having difficulty falling pregnant into a number of different groups, according to their age and the cause of the infertility. Out of this, some generalizations and recommendations can be made (see Box 10.2).

Box 10.2 Choosing the right treatment

Major impediment to fertility – ART

Certain disorders leave open only one choice. For blocked tubes or very low (or absent) sperm counts, IVF is the best choice.

Minor impediment – young woman – TCM or other medicines

Minor impediment – older woman – ART or combination of ART/TCM

Relatively minor impediments to fertility (e.g., slightly low sperm counts, irregular ovulation, mild endometriosis and vague hormonal imbalances) tend to delay pregnancy rather than prevent it outright. Such factors can be treated with the less-invasive therapies first, e.g., nutritional regimens, TCM or clomifene.

Older women in this group might increase their chances of falling pregnant by using TCM, e.g., as preparation for or during ART procedures.

Combination of minor or undiagnosed factors – long-term infertility – TCM or ART

If a couple has been trying for a long time to have a child but there are no major pathologic factors in either party, it might be the combination of a number of minor factors all operating together that is preventing pregnancy. Statistical analysis tells us that two minor factors in combination can reduce fertility so dramatically that it can take on average 7 years to get pregnant; three minor factors in combination increase this disturbing figure to 40 years.¹

The answer in allopathic medicine is not to treat the minor problems but to circumnavigate them and orchestrate the conception in the laboratory (IVF). You may remember from Chapter 1 that allopathic medicine expects that its treatment of major impediments to fertility (with drugs or surgery) will make a useful difference but that its treatment of minor or subtle factors may involve risks which outweigh the benefits.

The opposite applies to TCM: not only do subtle (and functional) problems respond better than major (and structural) abnormalities but also, because Chinese medicine views the body as a whole, a combination of subtle problems can be dealt with all at once. If the combination of factors all occur in one of the partners, e.g., a long irregular menstrual cycle, inadequate levels of luteal phase hormones and mild endometriosis – then chances are they will all be seen as manifestations or complications of the one primary imbalance. In the example above, the TCM doctor might diagnose ‘Kidney Yin and Yang deficiency leading to Blood stasis’. One prescription can supplement Kidney Yin and Yang and regulate Blood (although the skilful doctor will emphasize different aspects at different times in the menstrual cycle).

If the combination of factors occurs in both of the partners, e.g., irregular periods and low sperm count, then both partners will need treatment.

No detectable abnormality – TCM

There is another situation where ART specialists advocate medical procedures to assist conception, and that is when, even though all the investigations show no abnormality, no pregnancy is occurring. ART is usually recommended if the couple has failed to become pregnant over a certain length of time, e.g., ≥1 year. It is reasoned that time and chance have had more than enough opportunity to produce a pregnancy but the hurdle (even though it has no label) is clearly too big.²

Once again, this rationale does not apply to the TCM perspective. For example, if a woman has a Kidney Yin deficiency at age 29 years, it is more likely than not that she will still have a Kidney Yin deficiency at age 34, unless steps have been taken to address it. So her infertility persists, despite many years of trying to conceive. However, intervention to strengthen the Kidney Yin even after 5 years of attempting to become pregnant is a valid and often effective clinical approach before resorting to ART.

Some older women (38+) with unexplained (other than age-related) infertility may benefit from a combined approach of TCM and IVF in the hope that the lower IVF pregnancy rate of this age group can be lifted a little.

A summary of these treatment options is given in Table 10.1. If at times there can be a serendipitous marriage between the two medical systems to achieve reasonably rapid and effective results, then we have found a happy solution. Infertility is an area where both Western and Chinese medical systems have strong, effective approaches and both have much to gain by listening to and using the strengths of the other.

Table 10.1

Summary of treatment options

Cause of infertility	Approach to treatment
Major impediment	ART
Minor impediment
Young woman	TCM, nutritional or lifestyle program, drugs
Older woman	ART plus TCM
Combination of more than one minor factor	TCM or ART
No abnormality diagnosed	TCM, nutritional or lifestyle program

Comparing Different Infertility Treatments

ART and TCM have such different approaches, philosophical underpinnings, and methods, that we might question whether they can in fact work together. But examining the context and comparing the approach, techniques and emphasis of these different types of treatment will afford us insights into ways they might best complement each other.

IVF and TCM – different approach

Traditional Chinese medicine is a medical therapeutic treatment and IVF is essentially a technologic strategy. IVF does involve drugs but they are not used in a therapeutic way, they are used to artificially stimulate many follicles to ripen – a process called controlled ovarian hyperstimulation. IVF does not look at the means to an end, it skips straight to the end. TCM can only work by improving or correcting the means (i.e., the Kidney deficiency, the Liver Qi stagnation, etc.), which hopefully leads to healthier gametes and healthier offspring. Table 10.2 outlines the different methodology and style inherent in these two approaches.

Table 10.2

IVF and TCM – different approach

IVF	TCM
Technological regimen	Therapeutic treatment
Sophisticated and involved	Basic and minimally invasive
Clinical personnel	Clinical personnel
Infertility specialist – drugs and surgery, pathology tests	Infertility specialist
Anesthetists – local or general anesthetics	Herbs and acupuncture
Nurses – injections and blood samples	Diet and lifestyle
Radiologists – ultrasounds	Exercise, Qi Gong
Embryologists – monitor fertilization and embryo development	Some pathology tests

The IVF clinic is sophisticated and uses advanced technology such as ultrasound equipment, blood testing labs, surgical tools, microscopes, and incubators. The Chinese medicine clinic is equipped with herbs and needles, and often only two bits of machinery – scales and a battery operated stimulator for electroacupuncture.

An IVF clinic is staffed with large numbers of people with different roles, reflecting the complexity of the technology.

The TCM clinic is often just one specialist who prescribes and administers different sorts of treatment and recommends relevant lifestyle changes. Sometimes pathology tests are ordered; these won’t necessarily change the treatment approach but they may indicate prognosis and progress.

IVF and TCM – different techniques

If we are to compare the philosophy behind the techniques used in these two medical models (see Table 10.3) the key feature is the holistic nature of TCM and the reductionist paradigm of modern medicine. In Western medicine, the mind and body are separated and the body is viewed, analyzed and treated as an entity which can be understood only by reducing it to its component parts. Such a Cartesian viewpoint, where we reduce the body to basic components separated from the whole, is nowhere so clearly shown as in IVF where the sperm and egg are put together outside the body in a dish in the laboratory.

Table 10.3

IVF and TCM – different techniques

IVF	TCM
Reductionist	Holistic
New	Time tested
Possible side-effects	Few side-effects
Some risk to mother and baby	No risk to mother or baby demonstrated
Quick acting	Slow acting

TCM looks at, and treats, the whole body and mind – the patient feels better, fertility is improved but in some cases the treatment process may be too slow to meet the specific needs of the patient.

The risks of IVF are yet to be fully elucidated. The procedure at a few decades old, is relatively new. From the TCM doctor’s point of view, it is the emphasis on quantity over quality that is the concern. The Kidney Jing, that hard-to-measure quality of inheritance, is ignored by IVF clinics. It may be some time before this risk, if it is real, can be fully assessed because large numbers of IVF babies have not yet tried to reproduce themselves.

Risks inherent in IVF to the mother include ovarian hyperstimulation syndrome and a higher frequency of pregnancy complications. An increased risk of developing non-invasive ovarian tumors has been shown in IVF patients.³ Other risks to the woman doing IVF include ovarian hyperstimulation syndrome, and side-effects of the drugs including abdominal discomfort, fatigue, and headaches. Chinese medicine treatment, because it has been tested and filtered through many hundreds of years of close observation has few side-effects or risks. Occasional digestive upset (from herbs) or bruising (from acupuncture) may occur.

Risks to the baby include higher rates of premature delivery, low birth weight, neonatal or later morbidity and birth defects. Such hazards are more pronounced in cases of multiple pregnancies but still apparent in singletons conceived with IVF.4–7

It is thought that some of these risks may be due to the infertility itself rather than the ART procedures. From our point of view, if the infertility was related to poor Kidney Jing in the first place, it is not surprising that this may be visited upon the offspring. TCM treatment of Kidney deficiency related infertility only succeeds if the Kidney is bolstered such that conception occurs and proceeds to a viable pregnancy and healthy offspring. Of course the sort of research done on IVF babies has not been done on babies conceived with the help of Chinese medicine, so it is impossible to assess the validity of this assumption.

However, the type of infertility appears not to influence adverse outcomes, i.e., women who were doing IVF because they had blocked tubes or because of male factor infertility showed no difference in adverse perinatal outcomes from other women. This indicates that the increase in adverse outcomes is more likely to be due to the procedures themselves than to the infertility which leads to their use.⁸

There is also evidence that defects in IVF babies are due to imprinting or epigenetic effects, i.e., the process (mediated by DNA methylation and stable chromatin modifications) by which certain genes are switched off or kept active. We know that in those first few days of life, chemical pollutants, dietary components, temperature changes and other external stresses can exert long-lasting effects on development, metabolism, and health, sometimes even persisting in subsequent generations.9–12 The impact of IVF culture medium and embryo manipulation is necessarily being closely examined in this context.

ART involves the manipulation of early embryos at a time when they may be particularly vulnerable to external disturbances. We know that environmental influences during embryonic and fetal development influence the individual’s susceptibility to cardiovascular disease ¹³ and it appears that IVF children may indeed be at risk of vascular dysfunction similar in magnitude to that in children suffering from type 1 diabetes mellitus.¹⁴ Angiomas appear to be more prevalent among IVF children.¹⁵

Intracytoplasmic sperm injection (ICSI), in particular, has some biologists worried. If sperm are unable to make it as far as the fallopian tubes to fertilize an egg, presumably they are substandard and are rightly being discriminated against by the heartless but necessary process of natural selection. Further, if the sperm collected in an IVF procedure and placed in a Petri dish with some eggs are still unable to carry out fertilization, their biologic credentials are further in doubt. In Chinese medicine terms, we would describe sperm that lack the necessary to carry out penetration and fertilization of egg cells as reflecting quite serious Kidney Jing deficiency. This is not a good thing to be visited upon the putative new life. Of course, if the Jing is so deficient that it is incompatible with life, then the stages of cleavage and division that should happen after the sperm is injected into the egg will not proceed.

These concerns about lack of Kidney Jing do not apply to the sperm collected from men who have had a vasectomy or have some other mechanical blockage. In this case, there is no reason to think that their essential vitality (or Kidney Jing) is in any way defective, and relying on the methods of ART may be the only hope they have for becoming fathers (or becoming fathers again). Similarly, the effects of infections or exposure to radiation or chemicals that are short term should not have lasting effects on the Kidney Jing.

The artificial insertion of the sperm into the egg cytoplasm can change the way the sperm chromosomes line-up with the egg chromosomes (especially the X chromosome),¹⁶ and there is an increased risk of babies having a sex chromosome disorder if they are conceived after ICSI from a father with a very poor sperm count.¹⁷ There are higher than normal rates of embryopathy after ICSI.¹⁸ And a higher incidence of birth defects compared with IVF babies conceived without ICSI.¹⁹ Overall, absolute numbers of babies born with birth defects in babies conceived using ART are small; less than 10%. Many of the birth defects are minor and can be corrected.

Other risks associated with ART concern the pregnancy itself. A retrospective study found significant increases in odds ratio for gestational hypertension, placenta previa, need for cesarean section, and pre-term birth in IVF (singleton) pregnancies.²⁰ ICSI appears to be related to a higher incidence of pre-term births and low birth weight babies.²¹

IVF is quick acting – a cycle is over in 4–6 weeks. However, not every IVF patient is pregnant in that time. Some IVF clinics have observed that if someone is going to get pregnant with IVF, they will most likely do so within 3 stimulated cycles.

On the other hand, improving the general health of the would-be parents and especially their gametes, can be quite a lengthy process, in particular the oocytes. It takes up to 9 months to nourish a follicle and its egg through all its stages of development from a nascent preantral stage. Sperm develop over a 3-month period and appear to respond quite rapidly to some treatment – some studies saw improvements after just 5 weeks of acupuncture treatment (see Ch. 7).

Typically, a treatment cycle with TCM that aims at improving the environment of the ovary and the eggs, might span 4–6 months or more, compared with the 4–6 weeks of a single IVF treatment cycle. TCM also aims to improve female fertility in other ways – specifically improving ovary function, regulating the menstrual cycle and balancing hormones. In this case, results can be seen more quickly, often around 3 months. In the case of relaxing the fine muscles of the fallopian tubes, the effect can be more immediate.

In summary, where TCM treatment of infertility is holistic, time tested and generally slow acting with few side-effects and little risk, IVF is specialized, relatively new and quick to get results but not without possible (though small) risk to mother and baby.

However, the results IVF achieves ensure that it is a technique which is here to stay. Most of the common criticisms made by patients about IVF (it is invasive, impersonal, experimental, and expensive) are compensated for by the fact that it provides results for a good number of the couples who use it. The price of any powerful and rapid medical protocol is the inherent risk involved (as we saw in Ch. 1).

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