Traditional Chinese medicine treatment of the IVF patient

11


Traditional Chinese medicine treatment of the IVF patient




Using TCM in Preparation for an IVF Cycle


Once a full TCM diagnosis of the cause of infertility or other conditions is made, we follow the protocols outlined in detail in Chapter 4.


In an ideal situation, 6–9 months of ovary ‘make over’ is advisable. This allows time to remove factors that might be toxic to ovary and uterine health, like internal Heat or Damp, stagnant Blood (such as is found in endometriosis, PCOS, pelvic inflammatory disease, etc.), and includes identifying and avoiding workplace and domestic pollutants and lifestyle changes such as optimizing good diet and minimizing certain dietary ‘indiscretions’. It is also an appropriate period of time over which Kidney Jing can be replenished with herbs and the function of Kidney Yin and Yang can be improved with tonics for the Yin, Yang, Qi and blood. This will not increase the number of eggs in the ovaries but well nourished eggs in a balanced hormonal environment can be more responsive to stimulation by FSH from the pituitary or the pharmacist’s EpiPen. However, it is rare that a patient who has reached the point of considering IVF, or doing further IVF, will be in a position to spend 9 months doing this sort of preparation. Often, anything is better than nothing, and I try to persuade patients to consider at least 3 months of preparation before starting IVF (again).


Some women who are not infertile but are doing IVF due to male factor infertility will choose to use TCM treatment to prepare their body for optimal outcomes. A diagnosis is done in the usual way, considering the constitution and any symptoms. But additionally, we are mindful of increasing ovarian resilience and response by boosting Kidney function, and will also be mindful of clearing any signs of stagnation in the uterus. It is usually the case that a shorter preparation time is necessary for these women, unless there are significant general health issues.


Our approach to treatment of women with infertility will be according to the four categories of infertility we have previously described (Kidney deficiency, Liver/Heart Qi stagnation, Blood stagnation, Phlegm-Damp obstruction). We shall discuss each of these categories and describe a simplified approach to treatment with herbs that can be undertaken in the weeks or months leading up to IVF.



Kidney deficiency (and egg quality)


A large number of the women seeking help for infertility from the Chinese medicine clinic and the IVF clinic fall into a Kidney deficient category. These are often women in their late 30s and early 40s, or those who are depleted by overwork. If they have already attempted some IVF cycles they will often have heard from their specialist that their egg quality is not so good.


Egg quality is something mentioned in hallowed terms in IVF clinics because it is somewhat unfathomable and seemingly beyond the influence of the IVF specialists or scientists. Some ovaries age more quickly than others and unfortunately, neither acupuncture nor Chinese herbs (nor much else) can increase the number of eggs left in the ovary or change the integrity of the chromosomes. Nobody, not even the most skilled doctor, can improve the genetic quality of an ‘old’ egg because its genetic material was created decades earlier, when the woman was an embryo herself, and it has been subject to the relentless cellular wear and tear of decades. However, there is more to an egg than just its DNA and it is in consideration of its other components that we hope to apply some influence.


The environment that eggs occupy during their lengthy maturation process inside the follicles of the ovary has an impact on what shape they are in before meeting a sperm (with or without an IVF embryologist in attendance). They need a good blood supply, sufficient oxygen, adequate amounts of the right nutrients, the right hormone signals and the capacity to supply enough energy to the embryo.


This has important implications, particularly for eggs that are coming from slightly older ovaries (or where AMH levels are low or FSH levels are elevated) and possibly for eggs coming from women with PCOS or endometriosis.


The question is, can Chinese medicine be used to rejuvenate some oocyte characteristics by improving delivery of oxygen and nutrition to the developing egg and enhancing capacity to make energy (ATP), thus increasing the chances of making viable embryos? There is evidence to say that it can.


Research has shown that eggs that come from follicles with optimal blood supply and oxygen content have higher fertilization rates and developmental potential leading to improved IVF outcomes.1


The blood supply to the follicles in older ovaries is reduced at the later stages of their development, meaning that these eggs do not receive optimal oxygen or nutrition,2 which may be a contributing factor to the poor quality of older eggs. Unlike chromosomal integrity, this is something we can influence.


Acupuncture has been shown to promote the growth of new blood vessels (angiogenesis)3 and to specifically increase blood flow to the ovaries.4


In summary, we could say that the use of certain acupuncture point combinations, stimulated with a gentle electrical pulse can promote blood supply, and delivery of nutrition and oxygen to the follicles and therefore hope to improve their potential to fertilize and create embryos. Another way we may be able to improve egg quality is by improving the egg’s capacity to make energy so that it can impart this enhanced capacity onto an embryo after fertilization. The organelles in the cytoplasm of the oocyte, called the mitochondria, have been identified as possible markers for egg and embryo quality. These powerhouses of the cell, which are donated from the egg to the embryo, are responsible for providing energy for cell division and metabolism in a process called aerobic respiration.


Those oocytes that consume more oxygen before fertilization (i.e., have more active aerobic respiration), are the ones which form better quality embryos.5


The early pre-implantation embryo occupies a low oxygen environment (the fallopian tube or the Petri dish in the IVF lab) and relies on anaerobic as well as aerobic respiration. By the time the embryo reaches the uterus (Day 5 or 6), it needs not only good numbers of mitochondria but optimal mitochondrial function and ATP production via aerobic respiration to succeed in implanting.6


It is at this level that Chinese medicine hopes to exert some beneficial influence by ensuring the number and activity of the mitochondria in the ripening eggs is optimal. We know that eggs with more energy (ATP) have a better chance of making viable embryos and that the rate of division and successful implantation of embryos has more to do with how much energy they have than with maternal age. However, the mitochondria of older eggs are not so good at producing ATP7 and the eggs of poor responders to IVF drugs have three times less mitochondria than those of good responders.8


Similarly, it is known that older follicles have fewer antioxidant defenses against cellular damage caused by aerobic respiration and oxidative stress,9 and that this too is related to poorer IVF outcomes.10


The ART embryologists have been experimenting with adding younger mitochondria to the eggs from older women to see if this helps to make better embryos. The Chinese herbalist uses Kidney Yang herbs to do the something similar. These are the herbs that we saw added to fertility formulas in the late stages of the follicular phase (Phase 3) (see Ch. 4).


Interestingly, researchers have shown that it is precisely these particular herbs (used in fertility clinics in China for many centuries!) that markedly enhance mitochondrial activity and ATP production in laboratory studies on mice, while other herb categories such as Qi or Yin tonics have little effect on mitochondrial ATP production. These same herbs were shown to enhance antioxidant defenses at the cellular level.11


What the ancients knew from trial and error scientists are now proving in labs. We must bear in mind however, that for the doctor of TCM, the clinical experience of thousands of years of Chinese herbalists treating infertility carries more weight than the lab findings examining mouse tissues. That is not to say it isn’t satisfying when a new science can verify an old one.


Thus, we might surmise that the Kidney Yang herbs that are taken in the days leading up to ovulation, when the egg is maturing, can boost mitochondrial function, which then gives a newly formed embryo an advantage by dint of increased energy making capacity to aid development and successful implantation.


The herbs in Box 11.1 were found to increase ATP output in mice tissues. They are listed in descending order of effectiveness.



Box 11.1   Herbs shown to increase ATP production in laboratory studies




Thus, when we are choosing which Yang herbs to add to our formulas in the days before ovulation, we might consider not only the characteristics we examined in Chapter 4 when constructing our formulas but also the potency they have shown in laboratory tests.


Back to the clinic and to our patient who is concerned with egg quality, we must recognize that we have a condition, Kidney deficiency, that is not one that responds quickly to treatment – it takes time, rest, regular routines, reduced stress, adequate sleep, good nutrition and the sorts of treatments a doctor of Chinese medicine can provide.


However, time is usually the one thing these women often don’t have. They are anxious to get to the IVF clinic, or back to the IVF clinic, hounded by the ticking of the biological clock and the sound of their IVF specialists voice saying, ‘You shouldn’t have left it so long!’ But the sad irony is that for these women, IVF or repeated IVF, only drains the Kidney further.




What to do? …

In the case of a woman who is older or who has responded poorly in previous IVF cycles and now wishes to add a TCM approach, we focus especially on ovarian function and egg quality. This is done in exactly the way we described previously, by focusing on strongly reinforcing Kidney Jing, Yin and Blood. Ideally, this is done over a period of 6 months or more but even if only 3 months of strong Kidney Jing and Yin nourishment can be maintained alongside important lifestyle changes, then some changes will be achieved and hopefully responsiveness and resilience of the ovary will be sufficiently improved.


If your patient is actively trying to conceive, then use the treatment principles outlined in Chapter 4 for Kidney Jing and/or Yin deficiency. However, your patient may now be planning or waiting to do IVF and may no longer be trying so actively to conceive naturally. You and she may prefer an approach that is a little simpler than the complex 4-Phase one. In this case, you can combine the ideas inherent in both Phases 2 and 4 to create a formula which can be taken all month.


A comprehensive formula which combines both Gui Shao Di Huang Tang with Kidney Jing and Yang tonics is appropriate for across the board use in Phases 2, 3, and 4.





Herbal formula: Such a formula can be modified to take into account Yin-deficient Heat with the addition of Zhi Mu and Huang Bai. If the Spleen is weak you may need to increase the amount of Sha Ren and reduce the amount of Shu Di.



This expanded version of Gui Shao Di Huang Tang prepares a woman for IVF by reinforcing the Kidney Yin, Yang, and Jing, and calming the mind.


This formula can be taken for 3 or more months, with a break during the period if required. As we saw in Chapter 4, the main action of Gui Shao Di Huang tang is to reinforce Kidney Yin and the Blood. Here, we add herbs that support Kidney Yang as well, and herbs to calm the mind and keep the Qi and blood moving smoothly, so that it is applicable at all times of the cycle. Should your patient conceive during this preparation time, then switch formulas to one focusing on miscarriage prevention (see below).


During the menstrual period, a formula based on Tao Hong Si Wu Tang (see Ch. 4) could be taken.


Acupuncture treatment used to prepare for IVF will take into account patient circumstances, constitutional factors and the time of the cycle. (Follow the principles outlined in Ch. 4, and refer to Tables 4.1–4.7.)



Heart and Liver Qi stagnation (and sleep and stress)


As mentioned above, it is women with Heart and Liver Qi stagnation who benefit greatly from treatment during the IVF cycle, however preparatory treatment to regulate the cycle and calm the nervous system will also pay dividends. Sometimes in a big way, these patients are quite likely to respond quickly to acupuncture and may conceive before the (next) IVF cycle.


Treatment protocols following the 4 Phases are those found in Chapter 4. If, however, a simpler approach is required, then combining an expanded version of Gui Shao Di Huang Tang with elements of Xiao Yao San or Gan Mai Da Zao Tang could be taken all month to prepare your patient and her ovaries for IVF.







Herbal formula: The formula of choice is:



Using this sort of formula to prepare for IVF will provide support for the Kidney Yin and Yang and Blood at the same time adding a little more focus on regulation of the Heart and Liver Qi. The actions of Gui Shao Di Huang Tang and Xiao Yao San we have discussed before. The sweetness of Da Zao, Gan Cao and Fu Xiao Mai (Gan Mai Da Zao Tang) soothe the mind and relieve melancholy and sadness, commonly experienced by patients who have given up the possibility of conceiving naturally.


Should your patient conceive during this preparation time, then switch the formula to one focusing on early pregnancy support (see below).


During the menstrual period, a formula based on Tao Hong Si Wu Tang (see Ch. 4) could be taken. For acupuncture protocols, please refer to Tables 4.1–4.7 for general prescriptions, alongside modifications for Liver and Heart stagnation, Table 4.8.



Reducing stress


Apart from regulating the menstrual cycle and helping your patient’s mood, there is good reason to regulate the Liver Qi and reduce stress hormone levels before IVF. We know that stress can have a negative impact on IUI12 and IVF outcomes,13 and that women who have taken active measures to reduce their stress have had better results with IVF than those who don’t, especially if they are doing their second or more cycles.14–16 Women who do not feel depressed before starting IVF treatment conceive twice as often as women who are depressed before treatment,17,18 so ensuring healthy and unobstructed Liver Qi can have significant implications for a future IVF cycle.


Some researchers suspect that stress may impact specific factors in the endometrium as well as its general effects on hormones. It is not so easy to directly examine endometrial implantation sites in women trying to conceive, but studies on animal models have revealed a negative impact of stress on uterine receptivity and number of implantation sites.19 Stress, and its affect on fertility in general is discussed in Chapter 12.


The formula above addresses many of the aspects of infertility related to stress, but in more severe cases, the dose of He Huan Pi can be increased.



Improving sleep


Sleep quality and quantity (see also Ch. 12) should be a focus of our attention in the patient with an unstable Shen planning to do IVF, particularly if she suffers from insomnia. People with chronic insomnia tend to have higher levels of some cytokines, notably interleukin-6 and tumor necrosis factor.20 These immune factors can impact implantation of the embryo and placental development. Some researchers have proposed that a suboptimal cytokine environment can contribute to miscarriage.21 Certain cytokines can lead to clotting of the placental vessels in cases of early or late pregnancy loss, or interference of angiogenesis in cases of occult pregnancy loss.


The formula above can be further modified with Shen calming agents such as Mu Li and Suan Zao Ren, in the case of insomnia.



Blood stagnation


Treatment in the 3 cycles before IVF can be very useful in going some way to resolving blood stagnation, which might affect oocyte or endometrium quality. Most Blood stagnation pathologies affect the endometrium, whether they be ones that require surgery such as large submucosal fibroids or polyps, or ones not always so amenable to surgery such as adenomyosis, endometritis or diffuse endometriosis. Some forms of Blood stagnation appear to affect the egg quality as well as the endometrium quality, and this is also amenable to treatment. For example there is some evidence to show that Chinese herbs improve egg quality in patients with endometriosis by reducing inflammatory markers in the follicular fluid.22


Treatment protocols are those described in Chapter 4 with a large emphasis on clearing stagnation during Phase 1, during the menstrual flow. In this way, we hope to alter the endometrium and the way it forms in the hope that this will reduce risk of implantation failure. This sort of treatment aims to minimize the effect of immune and clotting factors which can jeopardize implantation and placenta formation.


Improving the hormonal and immune milieu of the ovaries of these patients with endometriosis with acupuncture or Chinese herbs in the months before doing IVF could have benefits similar to treatment of older ovaries, i.e., an improvement in the egg quality.


The progress of your treatment may be effectively monitored by menstrual symptoms such as pain or the nature of the menstrual flow.


A simplified approach using herbs in preparation for IVF would be the use of a Phase 1 type of formula such as that below, during the period, and at other times of the cycle if natural conception is not being attempted. Where your patient is still attempting to conceive, use the formula below (Tao Hong Si Wu tang modified) during the period followed by the next formula (Gui Shao Di Huang tang plus Tao Hong Si Wu tang modified) for the rest of the cycle to prepare the ovaries for the IVF drugs.







Herbal formula: The formula of choice is:



This formula which expands the reach of Tao Hong Si Wu tang (described in Ch. 4) is single pointed in its application to clearing Blood stasis and can be taken in the weeks leading up to an IVF cycle in patients who show clear signs of stasis, such as menstrual clots or abdomen pain. If the stasis is material and substantial in the form of endometriosis or fibroids then the relevant sections in Chapter 5 or Chapter 8 should be consulted.



This formula is an expanded version of Gui Shao Di Huang Tang combined with Tao Hong Si Wu tang (both described in Ch. 4) and other herbs to clear stagnation. The patient preparing for IVF can take this throughout the cycle to reinforce the Kidneys and clear stasis but should she conceive it should be discontinued and a formula to support early pregnancy given (see below).


In the case of endometriosis, formulas described in Chapter 5 should be taken in preparation for IVF (and natural conception avoided). Fibroids should also be addressed before doing IVF if they are large or multiple and affecting the endometrium; these treatments are covered in the Blood stagnation sections of Chapters 4 and 8.


For acupuncture protocols please refer to Tables 4.1–4.7 for general prescriptions, alongside modifications for Blood stasis, Table 4.9.



Phlegm-Damp (and weight loss)


Blockages caused by Phlegm-Damp should be addressed before IVF. Although mucus secretions in the fallopian tubes will be circumnavigated by the IVF process, the presence of Phlegm-Damp in the Uterus does not create a desirable environment for the transferred embryo.







Herbal formula: The formula of choice is:



This simplified approach, which can be used at any time of the menstrual cycle in the weeks before the IVF cycle begins, uses a modified Gui Shao Di Huang tang and combines it with a formula such as Jian Gu Tang (both described in Ch. 4), to strengthen the Kidneys and the Spleen and remove Phlegm-Damp.


Should your patient conceive during this preparation time, then switch formulas to one focusing on early pregnancy support (see below).


During the menstrual period, a formula based on Tao Hong Si Wu tang could be taken (see Ch. 4).


For acupuncture protocols, see Tables 4.1–4.7 for general prescriptions, alongside modifications for Phlegm-Damp accumulation, Table 4.10.



Losing weight


In the case of overweight patients, including patients with PCOS, acupuncture and herbs that aim to clear Damp can be extremely useful. We know that loss of weight and reduction in insulin resistance will improve ovarian function and egg quality. IVF success rates are higher in women with normal range BMIs. Acupuncture and herbs can be used to promote lipolysis, reduce appetite and increase metabolism generally. Weekly acupuncture sessions serve not only to boost Spleen and Stomach function to improve metabolism, but provide a regular checking in point where diet and exercise schedules are monitored and weight is measured. Patients with Phlegm-Damp accumulation can be difficult to motivate so persistence and encouragement is needed. But it is good to remind them that it is the initial mobilizing of Damp that is the crucial step in improving ovarian function. Once the first 10% of body weight is lost, or even 5 kg, ovary function will start to improve and the patient will be more motivated to continue with the treatment and the relevant lifestyle changes. (For more discussion on this topic, see Chs 5 and 12).


Note that it is not only women who need to pay attention to weight. It appears that obesity affects sperm negatively and this is discussed further in Chapters 7 and 12.


At the same time as helping weight loss, Chinese medicine can contribute to an improved environment in which eggs are maturing. Acupuncture using Spleen and Stomach points, which promote clearing of Damp, has been shown to reduce the elevated levels of testosterone and luteinizing hormone in women with PCOS both of which are thought to have a negative impact on egg quality.23 Some IVF specialists use Metformin or Glucophage ‘off-label’ to achieve something similar.


Like improving Kidney function, clearing Phlegm-Damp is not a quick process. However, patients in this category are often younger and have more time to prepare for IVF; 3–6 months is ideal. (See Chs 4 and 5 for more discussion of treatments for Phlegm-Damp Infertility.)



Preparation for IVF for men


It is worthwhile treating male factor infertility even if the couple plan to do IVF with ICSI. If the sperm vitality improves, ICSI may not be necessary. If it improves enough, IVF may not be necessary! (For the treatment of male factor infertility, see Ch. 7.)







Herbal formula: The formula below for reinforcing Kidney Yin, Yang and Jing and nourishing and invigorating Blood and Qi is applicable to any Kidney deficiency male factor infertility and should be taken for some weeks or months before the IVF cycle. It can be taken in small doses by partners of women doing IVF who have no male factor but who would like to maximize sperm quality.



Bu Shen Yi Jing fang was discussed in Chapter 7.


If there are signs of Heat then replace Huang Qi and Yin Yang Huo with Huang Bai (Phellodendri Cortex) 9 g and Zhi Mu (Anemarrhenae Rhizoma) 9 g.


Acupuncture is applicable to male factor infertility and is recommended in the weeks before doing IVF for the same reasons that herbs are recommended, i.e., to maximize the chances of success and the possibility of not requiring ICSI. If the partner of a woman who will be doing IVF has a normal semen analysis but wishes to maximize chances of a good outcome, it is quite reasonable to offer acupuncture treatment based on his constitution and symptoms (if any), combined with points that have been shown in research to improve microcirculation in the testes.24 This is particularly useful if the patient is over 35 and/or has any signs or symptoms of Blood stagnation or Kidney deficiency.


Treatment will be continued for a course of 10 or 12 treatments, or weekly until the sperm donation on the day of OPU. (For further discussion of appropriate treatment where there is male factor infertility, see Ch 7.)



Acupuncture points: Choose from the following (and see Table 11.1):




































































SP-6 Sanyinjiao
Ren-4 Guanyuan
K-6 Zhaohai
ST-36 Zusanli
ST-29 Guilai
K-3 Taixi
BL-23 Shenshu
BL-52 Zhishi
DU-4 Mingmen
ST-30 Qichong
LIV-5 Ligou
LIV-8 Ququan
SP-10 Xuehai
PC-6 Neiguan
BL-32 Ciliao
BL-33 Zhongliao
CO-4 Hegu
CO-11 Quchi
LIV-3 Taichong
GB-41 Zu linqi
GB-27 Wushu

In summary, there are many ways we can use TCM to help couples prepare for IVF, both in terms of useful lifestyle and physiologic changes such as diet and weight loss, and improvements to sleep and stress levels and so on but also, specifically in terms of maximizing egg and sperm quality. Box 11.2 summarizes some of the useful ways (based on early research findings) we can possibly help couples in the months before they embark on IVF.



Box 11.2   Summary of influences on sperm quality, follicular microenvironment and egg quality in preparation for IVF





Treatment During the IVF Cycle


When treating the IVF patient in the TCM clinic, we do exactly what we always do as Chinese medicine doctors, and analyze precisely what we see in front of us from a TCM perspective and administer treatment according to our diagnosis and according to what we have learnt about the treatment of infertility from experts over the centuries of TCM history. Some of what we learned (see Ch. 4) about specifically timed treatments for female functional infertility will still apply in the context of an IVF cycle, however we will need to make some adjustments for altered physiologic conditions and symptoms arising as a result of IVF drugs. This is a new frontier for Chinese medicine doctors, both in the West and also for those in China. We do not yet have the wealth of experience of generations of experts working with IVF patients to guide or inform our approach to treatment. What I present here is a brief summary of programs we have been developing in specialist support clinics set up in Australia for IVF patients. These clinics have seen several thousand patients at the time of writing, with the result that a lot of data has been collected. This sort of information, along with the clinical experience and trials being run by our and other centers will, over time, inform and refine treatment that is appropriate and most advantageous for the patient preparing for, and undertaking IVF. But in terms of TCM, clinical experience is still in its early days, and until such time as more experience and data is available, all the treatment suggestions made below must be seen as just that – considered suggestions.


Chinese medical treatment of internal disorders including infertility, relies on herbal medicine; while this approach may well be comfortable from the Chinese medicine doctor’s point of view, it can be worrying from the IVF specialist’s point of view. There is a concern that there may be unexpected or unfavorable interactions with the IVF drugs. This is a valid concern, since no studies have been done that I am aware of which examine the interaction of Chinese herbs with IVF drugs. Uncontrolled interference with medications can cloud the clinical picture.


If fruit juices like apple, orange, or grapefruit can interact with drug metabolizing enzymes and drug uptake transporters25 then we must assume that herbs may do something similar (although IVF patients are not told to avoid fruit juice, yet!).


Anecdotally, there are Chinese medicine practitioners and IVF specialists in this country who are quite happy to combine the two medicines and apparently with no untoward effect, in fact possibly the opposite. However, these practitioners are in the minority, and at the support clinics we do not prescribe herbs during the drug phase of the IVF cycle (up until egg collection). Until drug interaction studies have been done, most Chinese herbalists should take the cautious approach of advising their patients to stop taking Chinese herbs for a 5–7 day washout period before they begin taking their IVF drugs (the half-life of most aqueous herbal compounds is measured in hours rather than days or weeks, so this timeframe is more than adequate). This applies especially in the case of the agonist and antagonist downregulating drugs. These drugs prevent the pituitary gland producing hormones to stimulate the ovaries, and prescribing herbs that promote reproductive function (Kidney tonics) at the same time is counterintuitive, at least theoretically. Our clinical observations (and those of thousands of gynecologists in China before us) indicate that Kidney Yin herbs have the capacity to promote ovarian activity and increase their estrogen output, e.g., many patients report more regular menstrual cycles, stronger menstrual flow and specifically, increased secretions of cervical mucus when they take these herbs. However, we don’t know the mechanism by which these herbs are achieving this. We can say however, that the use of Kidney tonic herbs to promote ovarian function at the same time as the administration of FSH is at least theoretically, a clinically congruent action.


Additionally, we need to be aware of overall drug load on the liver’s detoxification systems. Women who are getting side-effects like nausea, headaches, rashes or fatigue may be showing signs of an overloaded liver. Adding more substances to the mix may risk exacerbation of these symptoms or worse.


Having made this point loud and clear, I now wish to add that there are circumstances where the addition of Chinese herbs to an IVF cycle appears to be useful and also acceptable. If an IVF patient has completed two or more stimulated cycles, with poor response to the IVF drugs and no or very few embryos produced, then patients and their specialists may well be looking for something else to try. This is often where the Chinese herbalist can step in, with the encouragement of the patient and the blessing of the IVF specialist (or at least a ‘we have nothing to lose’ viewpoint). We hope that treating Kidney deficiency may increase the responsiveness of the ovaries to the drugs (given enough time), and that treating Blood or Qi stagnation may increase implantation rates.


Since downregulating and FSH drugs are given by injection (or by nasal spray), interference of uptake and absorption by herbs taken orally may not be a critical issue, however separate timing of administration of IVF drugs and herbs by 4 h is recommended to reduce possible interactions. Response to the herbs and the drugs should be monitored regularly and doses of herbs reduced if the patient is getting side-effects such as nausea, dizziness, or headaches.


For cycles involving the transfer of frozen embryos, there is no contraindication to the taking of Chinese herbs. Similarly, in artificial insemination cycles where downregulating drugs are not being used, there is no contraindication to the use of Chinese herbs. The use of Chinese herbs with ovulation inducing drugs such as clomifene has been well documented and researched in China and is strongly recommended.


We mustn’t forget however, that preparation with Chinese medicine treatment for ovary health and gamete vitality is best done well before IVF is started (3–9 months). While that opportunity does not always exist, it is important that patients and IVF specialists realize that it is the contribution that can be made before the IVF cycle that is the real place of Chinese medicine.


Of course it goes without saying that concerns about drug interactions do not apply to acupuncture, which can and should continue to be applied according to standard TCM diagnostic and treatment procedures (combined with research-based protocols where appropriate) during the IVF cycle. The use of Kidney channel points with their possible stimulatory action on the pituitary or the ovary during a downregulated phase, is unlikely to adversely impact a pituitary gland that has been switched off pharmaceutically.


The practitioner must have a good understanding of the IVF process and will take into account all clinical symptoms or side-effects arising as a result of the IVF drugs into his/her diagnosis.



4-Phase TCM treatment during the IVF cycle


Treatments according to the 4 Phases we described in Chapter 4 can be modified for use during the IVF cycle. In Chapter 4, when we applied the 4-Phase treatments we maintained a close awareness of the natural physiology of the menstrual cycle and applied treatments that followed these. However, in the case of the IVF patient, we must now be aware of the physiology of the drug manipulated ovary. Rather than enhancing the natural processes of the menstrual cycle as we did in Chapter 4, we must now track and support what are essentially pathologic states as some of the pituitary and hypothalamus activity is shut down and the ovaries are artificially hyper-stimulated.


Suggestions made here for herbal prescriptions to be taken during the IVF cycle (for those patients who have a history of poor response to IVF drugs, as discussed above) follow the requirements of each of the 4 Phases of the menstrual cycle, manipulated as it is. However, in comparison with the complex and many layered approach to treatment of infertility the doctor of TCM takes as primary practitioner, here we take a simpler role as a support practitioner to the IVF specialist.


We need to be clear about what it is exactly that we are supporting in this physiologically artificial and manipulated situation. Essentially, we are assisting the patient emotionally and her ovaries physiologically. Our aims are to:



Assisting the ovaries as they are induced by non-physiologic doses of FSH to ripen multiple eggs means in TCM terms supporting the Kidneys; this is usually achieved with the use of herbal medicine. This sort of treatment will most often be requested by the ‘poor responder’, as we discussed above. The ovaries of women with depleted Kidney Qi, or those who have done a lot of IVF cycles, tend to respond poorly to stimulation by IVF drugs.


IVF patients who do not need this support (the ‘good responders’ who produce adequate numbers of eggs and younger women) may request Chinese medicine treatment during their IVF cycle to deal with stress, anxiety and side-effects. This is best achieved with acupuncture and administration of herbal medicine is not indicated in these cases.


The guiding prescriptions offered as support for IVF patients who are not good responders and have a history of failed IVF cycles address the immediate situation (namely, ripening of ovarian follicles) as much as the patient with her original infertility diagnosis. Hence, compared with the guiding formulas described in Chapter 4, there are fewer modifications required relating to the original cause of fertility.


Here, we will describe the 4 Phases of the menstrual cycle modified to take into account the effects of the drugs used in an IVF cycle. For women on a long downregulated IVF cycle, drugs will be administered before we actually get to Phase 1 (the menstrual phase) and these GnRH agonist drugs tend to delay the period. At this point, what is required is regulation of Qi and Blood to encourage menstrual flow and to prevent stagnation. Acupuncture to regulate the movement of Qi and Blood is particularly helpful at this time. Additionally, we want to support the Kidneys and their Jing, as they prepare for the demands on them once the stimulating drugs commence. Except in the circumstances described above, herbs are not usually prescribed during this downregulating phase and if your patient has been taking herbs in the preparation phase for IVF, then she will usually be advised to discontinue them before she starts the GnRH agonist.


Once the period arrives, we shall arrange our treatment according to the 4 Phases as described below.



Phase 1 (menstrual period) Day 1–3



Drugs: FSH ± GnRH agonist

You will recall that the main aim of Phase 1 treatment is to encourage an efficient removal and remodeling of the endometrial layers such that the uterine environment is conducive for implantation of an embryo that might arrive later in the cycle.





Acupuncture points: Acupuncture is usefully applied in this phase to promote movement of Qi and Blood – choose from the points below and see Table 11.2:



Table 11.2


Acupuncture pointsa suggested for use during an IVF cycle: menstrual phase




































Treatment goal Acupuncture points
To open the uterus and encourage downward movement and a smooth and thorough discharge of the menstrual flow CO-4 with SP-6
To moderate this action and hold the Qi Ren-6
To treat all aspects of the Blood, both its movement and its supplementation and control heavy bleeding if there is Heat SP-10
To remove obstructions to Blood flow SP-8
To move Blood in the Chong channel KI-14
To regulate the Qi in the uterus and moderate the descending action of SP-6 Tituo
To regulate Qi in the lower Jiao BL-25 and BL-30
To regulate Qi specifically in the Uterus BL-32, Shiqizhui
To regulate Qi, particularly if there is pain in the sacrum Baliao (BL-31–34)
To make Blood flow smoothly, relieve pain, calm the mind PC-5

aUse reducing method on leg and trunk points and even method needling on wrist points.

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Related posts:

  1. A tale of two clinics — the treatment of infertility with Chinese medicine or Western medicine
  2. Assisted reproduction technology and in vitro fertilization
  3. Diet and lifestyle
  4. Gynecologic disorders which can cause infertility

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Jul 11, 2016 | Posted by in PEDIATRICS | Comments Off on Traditional Chinese medicine treatment of the IVF patient

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