Acupuncture for IVF and Assisted Reproduction - An Integrated Approach to Treatment and Management

The management of infertility using acupuncture is an expanding area of practice and one which is frequently rewarding for TCM acupuncture practitioners.

Acupuncture for IVF and Assisted Reproduction has been specially prepared to meet the growing demand for information in this area and draws upon 20 years combined experience of the authors together with the latest evidence from both orthodox medicine and TCM.

Richly illustrated and clearly written throughout, the book takes the reader through the anatomy and physiology of reproductive medicine (from both an orthodox and TCM perspective) and explains the underlying basis of orthodox medical fertility tests and investigations. The volume then explores the pathology and aetiology of TCM syndromes and shows how common fertility-related conditions, such as endometriosis and male factor infertility, affect Assisted Reproductive Technology (ART) success rates. It explains in great detail how to take a reproductive medical history and successfully diagnose TCM syndromes. Acupuncture for IVF and Assisted Reproduction also provides guidelines on how to regulate the menstrual cycle in preparation for IVF treatment and shows how lifestyle can affect fertility and ART success rates.

Placing a strong emphasis on the practical aspects of patient care, Acupuncture for IVF and Assisted Reproduction contains an abundance of case history templates, algorithmic acupuncture treatment pathways and patient fact sheets and will be ideal for all acupuncture practitioners working in this field.

The treatment of infertility with acupuncture has grown hugely in popularity over the last 15 years, and the scarcity of literature available on the subject shows that publishers have struggled to keep up with the demand for quality information in this area. Mainstays such as Maciocia and Lyttleton provide a sound basis of information on TCM theory and practice, but are mostly focused on facilitating natural conception. Many of the patients seen by acupuncturists on a day-to-day basis often wish to explore all of their options at once, combining modern assisted reproductive technology (ART) techniques and complementary approaches. In this book the authors attempt to cover the treatment of such clients.

This is without doubt an ambitious book, and its ambit is really much larger than the title suggests. It might be more appropriately labelled as a practical guide to the treatment of infertility with acupuncture. We are nearly halfway through the book before the fundamentals of ART are properly introduced, with the first third devoted to typical TCM gynaecology and fertility theory. Throughout the ART sections, the underlying pathology is extensively dissected. Although this makes much of the text fairly typical of other gynae/ fertility texts, it seems essential for this book to work, given that the theoretical basis of acupuncture treatment alongside ART is essentially inseparable from gynaecological work in general. The sections on frequency and timing of intercourse and the use of basal body temperature (BBT) charts (which seem somewhat redundant in the context of ART/IVF treatment) do little to restrict the book's coverage, and the sheer scope of the book, with its multiple interlinking themes, means the structure becomes somewhat messy.

This book is extremely well researched and referenced. Its strong biomedical leanings will appeal to many, although its TCM content seems somewhat scant in comparison to other texts in the field. However, the inherent problem in writing a book with a strong biomedicine focus is that biomedicine itself has not reached a consensus on many of the principles, protocols, methods and medications used in assisted reproduction. In many cases, for each referenced article quoted by the authors to support their argument, several others might be cited that support a different opinion. Subjects such as the predictive value placed on FSH and AMH levels are presented as if they are agreed norms, yet there is actually considerable debate as to their accuracy and meaning. Despite the close attention and hard work that has obviously gone into this book, the authors struggle to hold on to the slippery beast that is modern biomedical fertility treatment. Due to the rapidity with which biomedicine shifts, develops and evolves its techniques and theories, this book may have a limited lifespan. In addition, reproductive immunology is given short attention, with the authors claiming this complex area lies outside the scope of their text; for an important and rapidly expanding area, this subject perhaps deserved more attention. The authors also do not address the significant differences in approach between ART clinics. There can be huge differences between the tests and treatments provided in a private central city clinic compared to a rural NHS unit. Presumably this book is reflective of the clinics attended by patients of the authors, but this means that some practitioners may feel that it does not reflect the ART treatment being used for their patients. For example, at our central London clinic we see patients taking medications on a daily basis that are given scant or no mention in the book, and other drugs being taken at dosages far in excess of the stated maximum. Understanding the approaches of particular ART clinics is important for acupuncture practitioners, and any practitioner who passes on to their patients the testing regimes recommended here (immunology, thrombophilia or genetic screening for instance), may find that their particular clinic simply does not offer them.

In a book so firmly rooted in references, it seems odd that authors veer off into conjecture when it suits them. For example, acupuncture on the day of embryo transfer is the singularly most researched aspect in this area, with multiple papers presenting positive results and several presenting negative or statistically non-significant results.

Almost all of the positive papers present timing as an integral aspect of success, with the most beneficial acupuncture treatment being performed shortly before and after embryo transfer. However, the authors state that such timescales should not be rigidly adhered to, and that in their experience acupuncture treatment 24 hours before and after transfer can be just as effective. Without evidence this advice appears to be based on the logistics of the acupuncture clinic rather than evidence-based best practice.

Where the book is most useful is in its clear acknowledgement that practitioners working in this area need skills far beyond acupuncture techniques in order to be successful. The sections on patient management are very good. Given that IVF units are frequently too busy to provide the necessary emotional or informational support to patients, managing expectations and the disappointment when treatment fails is an integral part of the fertility acupuncturist's day-to-day life. The nutritional advice presented (including vitamin and mineral supplementation) is welcome, and although it would have little place in a classical TCM text, represents a commonplace aspect of good clinical practice. However, although male factor subfertility is considered to be involved in 50 per cent of infertility cases, the authors only dedicate a few pages to its treatment. While in private practice female patients often predominate, part of our role as practitioners is to educate patients as to the full extent of what might be achieved if both partners were treated appropriately.

For a book that attempts to deal with the practical reality of treating alongside ART, more difficult areas - such as getting second opinions, obtaining further testing and even practitioner disagreement with ART clinics - that are common in clinical practice tend to be skirted around. Similarly, although the relevant TCM patterns are perfectly well documented, they are all given a similar weighting, without pointing out, for example, that there is little that can be done about a pattern of Kidney jing deficiency if the patient turns up ten days before their egg collection. All in all there could be much more clinical guidance to inform practitioners what is or is not possible.

Overall, this is a difficult book to read. There is much information here, but the reader has to work hard to extract it. It is an interesting addition to the existing literature on this subject, and will likely appeal more to medical acupuncturists or those with a strong biomedical leaning, but we are still yet to have a defining text on this subject.

Daniel Elliott

1. Subfertility overview

Introduction / Definition of infertility disorder / Prevalence of infertility / Major causes of subfertility from an Orthodox Medical point of view / Contributory subfertility factors: the Orthodox medical perspective / Causes of subfertility from TCM point of view / Reproductive history and development from an Orthodox Medical perspective / Reproductive history and development from a TCM perspective

2. Anatomy and physiology of the reproductive system: pre-requirements for conception

Functional anatomy of the reproductive system from an Orthodox medical perspective / Sperm and egg production / Reproductive physiology from an Orthodox medical perspective / Reproductive physiology from a TCM perspective

3. The magic of conception

Sexual intercourse / Sperm transportation up the female reproductive tract / Pre-fertilization sperm changes / Egg maturation and ovulation / Egg fertilization / Transportation of embryo down the female reproductive tract / Comparison of natural fertilization (in vivo) with ART fertilization (in vitro) / Embryogenesis / Implantation: the first communication between the mother and her embryo / Conception from TCM point of view

4. Orthodox medical tests and investigations: optimising patient care

The initial consultation / Tests and investigations overview / Tests and investigations- female / Tests and investigations- male

5. Investigations from a TCM Perspective

Medical and fertility history taking / Clinical observations / TCM syndromes diagnosis in subfertile patients / Basal Body Temperature (BBT) charting as a diagnostic aid

6. The fundamentals of ART

Introduction / Types of ART treatment / Pharmacological drugs used in ART / Embryo grading / Advanced ART techniques / The role of acupuncture in ART / Future advances in ART: a potential role for acupuncture?

7. Pre-conception care in preparation for ART

Weight / Smoking / Alcohol / Caffeine / Recreational Drugs / Medication / Environmental and occupational factors / Nutrition and supplementation / Exercise and rest / Stress / Relationship and sexual issues

8. Identification and management of conditions detrimental to IVF outcome

Tubal pathology / Ovulatory disorders / PCOS / Thyroid disease / Endometriosis / Unexplained subfertility / Secondary subfertility / Male factor subfertility / Regulating the menstrual cycle with acupuncture / Treatment planning: setting realistic goals

9. Acupuncture during ART

Treatment during IVF / Adapting treatment principles to natural IVF / Adapting treatment principles to mild IVF / Adapting treatment principles to Frozen Embryo Transfer (FET) / Adapting treatment principles to ovulation induction / Adapting treatment principles to IUI / Adapting treatment principles to egg donor IVF / Adapting treatment principles to surrogacy and gestational carrier / Adapting treatment principles to ZIFT/GIFT / Adapting treatment principles to IVM

10. Clinical issues during ART

Poor follicular development / Immature or no eggs / Suboptimal endometrial lining / No sperm / Fertilization failure / Poor embryo growth or growth arrest / Difficult embryo transfer

11. ART complications

Ovarian Hyper Stimulation Syndrome (OHSS) / Multiple gestation

12. Managing the patient with a complex medical history

Repeated Implantation Failure (RIF) / Miscarriages and pregnancy loss / Reproductive immunology / Reproductive immunology from TCM point of view / Implications for acupuncturists: to refer or not to refer?

13. The therapeutic relationship in acupuncture practice

Mutuality / Trust / Care / Challenge and performance / Return to mutuality / Measuring the success of acupuncture treatment / The effect of subfertility on patients / Legal and ethical considerations

14. Aftercare

Negative outcome / Positive outcome: healthy transition from subfertility to pregnancy / Acupuncturist’s self-care: saying goodbye to patients

Appendices

1. Templates

2. Basal body temperature (BBT) chart template and instructions

3. Investigation reference ranges at a glance

4. Fertility factsheets

5. Commonly used medications in ART

6. Medications known to adversely affect fertility

Glossary of Orthodox Medical Terms

Glossary of Traditional Chinese Medicine (TCM) Terms