Acupuncture and Chinese Herbs During IVF and Low Ovarian Reserve A Case Study

By Keren Zelicha

In recent years, there has been a marked increase in the number of women putting off pregnancy until their late 30s or early 40s. This is the result of many contributing factors including various socio-cultural considerations, among them media coverage of the subject which frequently focuses on the success of older women in becoming pregnant—and in this way, feeding into the general assumption that postponing pregnancy is possible with no price to pay.

In reality, later parenthood has contributed significantly to the rise in infertility and difficulty in conception. This phenomenon, combined with the availability and efficiency of fertility treatment, has led to a growing demand for in-vitro fertility treatment. Some women in their late 30s or early 40s undergoing fertility treatment may occasionally encounter a lack of response to treatment or difficulty developing multiple follicles despite injecting hormones according to the protocol. This situation comes about as a result of low ovarian reserve (a small quantity of eggs remaining). In general, it’s possible to point to the natural trend of gradually increasing FSH levels in women even by their mid-30s. Endocrine changes of this type are in fact already beginning to take place as long as 13 years before menopause. In 1989, Scott reported a prospective research evaluating the connection between high FSH levels and pregnancy rates. As the FSH levels rose, the rates of pregnancy and birth decreased. Further research involving 1,478 women undergoing IVF fertility treatments found that as FSH levels rose, the number of follicles, the number of ova retrieved, the number of embryos, and the percentages of implantation decreased.

There is no single definition today in the medical literature of the term “low ovarian reserve.” There are differences of opinion regarding the importance of certain tests, however it is generally agreed to choose several of them. The most common tests for determining low ovarian reserve are:

Hormone blood tests
1. Rise in FSH levels can be tested between cycle days 3-5
2. Low AMH levels (can be tested on any cycle day)
3. Low Inhibin B levels can be tested on cycle day 3
Ultrasound tests
1. Low number of antral follicles ( AFC) found on ultrasound at the beginning of the follicular stage
2. Low ovarian volume

It is important to point out that these measurements cannot predict the status of the ovarian reserve (number of ova), nor their quality or the chances of pregnancy.

in order to overcome the limitations imposed by lack of universality in definition of poor ovarian reserve ( POR ) in 2011 a working group in Bologna recommend the presence of at least two of the following three features for diagnosis of POR:

Advanced maternal age (≥40 years) or any other risk factor for POR
A previous POR (≤three oocytes with a conventional stimulation protocol)
An abnormal ovarian reserve test (i.e. AFC, 5–7 follicles or AMH, 0.5–1.1 ng/ml)

in addition, women over 40 years of age with an abnormal ovarian reserve test may be classified as “expected poor responders”

The following case study illustrates the process of integrating Traditional Chinese Medicine in a woman undergoing IVF treatment with a background diagnosis of low ovarian reserve:

Ruth, a single woman aged 41, is trying to conceive. After six months of artificial insemination which did not result in pregnancy, on the advice of her physician, she agreed to pursue IVF treatment. Her first period began at the age of 12, her regular cycle was between 26-28 days. She experienced four days of bleeding, of normal quantity and color. Her medical history included colitis, with one flare-up which had occurred a year previous, and since then, she had had no symptoms of stomach pain or diarrhea and was not being treated. She had regular bowel movements, good nutrition, and aversion to cold. Her pulse was weak and thin, her tongue was narrow and slightly tight, red tip, purplish on the liver area, with a white coating in the center. Hormonal profile testing revealed that her FSH level was 13.4 – slightly elevated. The Traditional Chinese Medicine diagnosis for Ruth was:

Kidney-Spleen qi deficiency, Kidney Yin Deficiency, Liver Qi Stagnation.

Ruth faced a long protocol that included administering Synarel (Nafarelin) nasal spray for about ten days before her period, and adding gonadotropin shots of Gonal F -450 units for five days, beginning on the second cycle day. After tracking follicles and blood tests, Ruth replaced the Gonal F injection with shots of Menopur (Menotropin) 600 units as needed.

Acupuncture points over the course of the protocol supported the Traditional Chinese Medicine diagnosis and included: St 36, Cv 4, Cv6, Kd 6, Lu 7, Sp 6.

During the retrieval, one follicle was found to be empty with no ovum. It is important to note that the dosages of medication that Ruth was receiving according to this protocol were the maximum and the expectation was that there would be a larger number of follicles containing eggs. After the failure of the protocol, Ruth took a one-month break over the course of which, in addition to support through acupuncture, she began taking a modification of Ding Jing Tang formula which included the following herbs:

Sheng di, Shu di, Shan yao, Tu si zi, Gou qi zi, Nu zhen zi, Mu dan pi, Bai shao, Chai hu.

This formula supports spleen-kidney qi and regulate liver Qi. The addition of Mu Dan pi, Nu zhen zi, and Sheng di created a common factor intended to strengthen the kidney Yin and clear deficient heat. Since hormone injections taken by women during fertility treatment can create symptoms of heat and stagnation, there is occasionally a need for regulating the liver Qi, cooling and invigorating the liver blood. The herb Mu dan pi is indicated for cooling and increasing liver blood flow. In the case of Yin deficiency, it is possible to add Gou qi zi, which supports the liver and kidney Yin. Additionally, Gou qi zi, combined with Bai shao, helps soften and nourish the liver blood, therefore, it is suitable for women presenting stagnation due to Qi and Yin deficiency.

The second protocol was a short protocol which included Menopur 600 units along with ovulation inhibition with Cetrotide (Cetrorelix) which was added when the follicles reached 13-14 mm. At this stage, Ruth felt anxious due to her failure in her previous treatment, as well as emotionally overwhelmed due to the protocol injections which caused liver qi stagnation symptoms. These feelings made the treatment difficult for Ruth and disturbed her rest.

During the process of follicle development, the treatment guidelines were as follows:

Supporting the Bao Mai axis to improve the connection between the heart – fire, and the kidneys – water; kidney Yin deficiency caused disquiet of the heart, therefore, points such Ht 5, Kd 4, Cv 4 were combined.
Regulating Liver Qi and calming the Shen- spirit: Liv 3, Pc 6.

Estradiol levels before eggs retrieval were high and good – 9,864 pmol/l, endometrial lining reached 8 mm. Despite seven follicles having been observed, only two eggs were extracted; the remaining follicles were empty. A single viable embryo was returned to the uterus. The treatment strategy after embryo transfer was supporting kidney and spleen Qi and calming the Shen- spirit. Acupuncture points chosen were Yin Tang, Kd 7, St 36, Liv 3, Pc 6. Treatment was unsuccessful.

The third protocol was upgraded to a “flair up” protocol over the course of which Ruth received Decapeptyl 0.1 (Triptorelin) for the first three days of her cycle. From the second day, Ruth injected Menopur 600 units and later on, Cetrotide (Cetrorelix) was added as needed until the egg retrieval time was determined. This protocol was aimed at improving the woman’s response to the administration of hormones and allow her to develop more follicles, therefore, it is more efficient for women with a low ovarian reserve. Common points used over the follicular stage included Cv 4, Cv 6, St 29, Gb 34, Kid 6, Sp 6. Uterine lining thickness was 8.8 mm, estradiol level before eggs retrieval was 7,786 pmol/l.

Five eggs were retrieved, two were fertilized and returned to the uterus. Acupuncture accompanying the embryo transfer included points such as Ht 7, Gv 20, Gb 34, Kd 7.

This combination was aimed at calming the Shen- spirit, strengthening the kidneys and stabilizing the earth. Gb 34 is an earth point therefore in addition to its ability to soothe the liver qi it can support earth. Women undergoing IVF treatments are in a state of mind of anxiety and instability, hence it is important to pay attention to their spirit and keep their ground stable.

After two weeks, b-hCG testing was positive. Ruth continued to receive support throughout the pregnancy and later successfully gave birth.

Treating women undergoing fertility treatment can be challenging, especially in women with low ovarian reserve, both from a perspective of the emotional support required along their journey to achieve pregnancy and from the perspective of enhancing their clinical response to the protocol treatment. It is important to remember that the goal of treatment is improving the response to the hormonal protocol and allowing them to attain a high-quality embryo or embryos to be returned to the uterus for implantation.

Treating Poor Ovarian Reserve And High FSH Levels

This article was first published in Hebrew at sinit website