Acupuncture Treatment for In-Vitro Fertilization – Case study

Dikla (not her real name) was forty years old, single, and had been trying to conceive for about six months before she came to my clinic. She decided to start acupuncture treatments after she’d heard that the combination of Chinese medicine during the course of in vitro fertilization could improve the chances of success.  Eight years previously, she had spontaneously become pregnant but opted to have an abortion and curettage performed.  So far, she had done three times Intra uterine insemination, once naturally and twice aided by hormones with Gonal F 150-225 units which produced only a single follicle.

The first IVF cycle she underwent, was a long protocol with Synarel (Nafarelin) and Gonal 450 units.  A single follicle was retrieved, however it was empty and no egg was found.  Currently she is undergoing her second IVF cycle which is a short protocol with Menopur (Menotropin) 450 units and Cetrotide (Cetrorelix).

Dikla reports receiving her first period at age twelve, her period is regular every 26-28 days, consisting 3-4 days of dark-red bleeding.  She does not experience period pain and there is no pre-menstrual syndrome.

Hormonal profile on day three of the menstrual cycle is: Prolactin 507 mIU/L , LH 9.2 IU/L, FSH 11.5 IU/L, E2 180 pmol/l, TSH 1.28 mlu/l

From analyzing the hormonal profile, it can be recognized that her FSH level is slightly elevated from the norm.  The standard upper limit of FSH is 10.

20 years previously, she was diagnosed with colitis following an incident of bleeding and diarrhea.  Therefore, for the last three years, she had been taking Rafassal (Mesalazine) before she gradually tapered off completely.  Two years ago, she had a similar relapse and after two months of treatment with Rafassal, experience improvement and remission once again.  Today, she has no digestive difficulties and is not taking any ongoing medication.  She has a bowel movement every other day, is experiencing fatigue, has a tendency to cold, and excellent sleep.

Tongue: Stiff and narrow, a little purple color with a dark-red tip. The coating is white in the center, sub- lingual veins are swollen.

Pulse: Thin and weak

Traditional Chinese Medicine Diagnosis: Kidney yin deficiency, spleen qi deficiency, liver qi stagnation

Treatment Strategy:  Strengthening and enriching kidney yin, strengthening spleen qi, regulating liver qi movement and balancing the Shao Yang system.

On the second day of her cycle, Dikla’s blood test revealed: Estradiol- 223 pmol/l, LH- 2.9 IU/L, Progesterone- 4.8 nmol/l.

The endometrial thickness was 5 mm.  Dikla reported that her period had been light and only on the fourth day of her cycle had she experienced an increase of heavy bleeding.  The explanation for the delayed start in her period could have stemmed from her high levels of progesterone (4.8 nmol/l) relative to the follicular stage.  Occasionally, in some women there is no steep decline in progesterone immediately with the onset of the period since the corpus luteum has not yet been absorbed and disappeared.  In these women, it is occasionally observed that their temperature, as well, will be higher relative to the start of their cycle and will not descend as expected the day before the period or on the first day of the period to a temperature of 36.3.  It should be noted that clinically this situation (high progesterone at the start of the cycle) is common in women with a low ovarian reserve, but also appears in other situations.  From a Chinese Medicine perspective, pathologies which could lead to this situation include qi or blood stagnation.  The period is not released and thus the yang is still “trapped” (progesterone which does not descend / temperature remains high).  Another reason for this is an imbalance between yin and yang which is disturbing their natural alternation process at the start of the cycle, possibly due to a yin deficiency and false heat.

Dikla arrived for treatment on the sixth day of her cycle, after four days of Menopur (Menotropin) 450 unit injections.  On the day of her visit, her blood values were: E2 646 (pmol/l) , Progesterone 0.6 (nmol/l) and the follicles were small.

Acupuncture points were selected in accordance with the follicular stage and the strategy of supporting spleen qi, enriching yin and blood, regulating qi and blood movement:  Cv 6, CV 4, Kd 13, Sp 4 Right- Pc 6 Left, Kd 7.

Kd 7 is a metal point on the kidney meridian.  This point is extremely important as a point of strengthening the kidney qi and relevant at the stage of folliculogenesis and not only at the luteal phase, as a point which supports the ying.  Along with Kd 13 (a local point which regulates the lower heating and normalizes the flow between Chong-Ren) this will support qi movement and blood in the pelvis, which are important for follicles growth.

After follow-up and after raising the level of Menopur to 600, six follicles were observed in sizes between 17 and 20 mm.  The hormone levels were high, demonstrating that treatment was at its peak from the perspective of response to injections:  E2- 9864 pmol/l, Progesterone 5.5 nmol/l.  Endometrial thickness rose to 8 mm.  Two days later, retrieval was arranged and two follicles were retrieved, however, ultimately, a single high-quality embryo was returned to the uterus.

Immediately after embryo transfer the treatment focused on regulating the movement of qi, emotional relaxation, and supporting qi:  Yin tang, Pc 6, Liv 3, St 36, Kd 7.

Unfortunately, this treatment cycle did not succeed and Dikla’s period returned.

Her third IVF cycle began after a one-month break, during which she took the contraceptive pills for two weeks.  The protocol chosen was of the “Flare” type – a short protocol with a GnRH agonist.  This treatment begins with injections of Decapeptyl (Triptorelin) from the first day of the cycle for three days only, and from the second cycle day, Dikla also added Menopure 600 units (a dose which is considered high).  This protocol was intended to encourage strong growth of follicles in the ovary and is aimed at women experiencing difficulty in recruiting a large number of follicles.

Dikla and I met on her third cycle day, after heavy bleeding had ceased, in order to begin supporting the endometrial lining of the uterus and follicle growth.

Acupuncture points selected were: Cv 6, Cv 4, St 29, Liv 3, Sp 6.

After eight days of injections, the endometrial thickness had reached 7 mm and 4 follicles were observed of over 15mm.  Blood test values were: E2 4358 pmol/l, Progesterone 2.3 nmol/l.

Acupuncture points selected were: Sp 4 (Right), Kd 3, Cv 6, Cv 4, St 29.

Four days later, retrieval was conducted.  Five follicles were retrieved.  Two embryos were produced, which were returned to the uterus.  Dikla received support from Endometrin ( vaginal Progesterone) three times daily.  This support provided the progesterone which was important for development of the embryo.  A day after the embryos were returned, we met for treatment.  At this stage, I do  not generally perform acupuncture on lower abdominal points in order not to create excess stress for the patient, who is experiencing difficulty dealing with the situation.

Acupuncture points selected were:  Kd 7, Ht 7, Gv 20, Gb 34, Sp 9.

Gb 34 is an earth point on the gallbladder channel.  This point creates stability within the wood element (Liv/Gb) which is in a state of imbalance as a result of the hormonal treatments. This point can regulate the balance between wood and the earth elements.  Following the hormone injections and the intensified effort to develop follicles, the wood element, which carries out the process of follicles growth, is exhausted and could create stagnation.  Additionally, the wood element influences the process of implantation since it is a source of emanation, a symbol of breaking through and is responsible for the beginning of life at this early stage of pregnancy.  Therefore, GB 34, which regulates the wood activity, is important and is selected after embryo transfer.

Beta testing was positive and Dikla gave birth to a lovely daughter.