Endometriosis associated infertility with acupuncture treatment

Women’s uterus wall has three layers: inner layer is called endometrium; middle layer is smooth muscle; outer layer is myometrium. Endometrium of uterus is special. It undergoes cyclic change and regeneration. During the period cycle, this layer grows thicker and is full of blood vessels and glands. It provides best hospitable environment for implantation of a fertilised egg. If pregnancy does not occur, the inner layer will shed away causing bleeding and the layer will redevelop. Sometimes, if things go wrong, the endometrial tissue can grow outside of uterus. This is a condition called endometriosis. The most common places where this tissue was mislaid are ovaries, fallopian tubes and the pelvic cavity. This misplaced tissue is also responding women’s period cycles, but it could not shed. As a result it will cause inflammation, scar and adhesion. Endometriosis could present chronic pelvic pain including period pain, and intercourse pain, irregular period and associated with infertility.

Endometriosis affects up to 10% of reproductive age of women. Endometriosis is associated with infertility. At least one third of women with endometriosis have infertility. Women with infertility are 6-8 times more likely to have endometriosis. Some women with endometriosis will conceive without difficulty, while others may have difficulty to conceive. Some controlled trial study showed that women with endometriosis were 10% less likely to conceive than those without the condition. The pregnancy success rate among women with endometriosis associated infertility was lower than those with unexplained infertility. A study of 14 randomised controlled trials showed that women with endometriosis were less likely than women with tubal-factor infertility to conceive by means of IVF. Endometriosis is also associated to lower live birth rate.

The mechanisms of association between endometriosis and infertility are not fully understood. Moderate to severe cases can lead to infertility. The connection between severe endometriosis and infertility is due to severe pelvic adhesions which cause a variety of anatomical abnormalities. This can affect ovum capture and transport. The severe ectopic endometrial lesions is also decreasing implantation rates, decreasing egg retrieval rates and decreasing pregnancy rates.

Most of endometriosis cases are mild. Some women with mild endometriosis have also had infertility and many women with infertility have had mild endometriosis. The cause and effect relationships between mild endometriosis and infertility are not clear. Severe endometriosis can cause reproductive organs scarring and distortion. The association of minimal and mild endometriosis with infertility is also possible. This is because endometriosis causes ovulatory dysfunction, impaired follicle development, defective implantation, eutopic endometrium abnormalities, abnormal immunological environment and luteal phase problems. Luiz Fernando et al collected the data from 1985 -2011 to investigate the association between mild endometriosis and infertility. They found there were two randomized controlled trials for this study. In 1997 Marcoux et al conduceted a randomized controlled trial studied the association between endometriosis and pregnancy rates. They compared pregnancy rates in 172 women with stage I and II endometriosis who underwent laparoscopic removing all visible endometrial lesions with 169 women who underwent diagnostic laparoscopy only. All women were followed postoperatively for 36 weeks. The cumulative pregnancy probability rate for the surgery group was 30.7% while pregnancy rate for the diagnostic group was 17.7%. This result showed significant differences between two groups indicating the association of mild endometriosis and infertility. This suggestion was supported by another study. The conclusion is that minimal to mild stages of endometriosis plays an important role related to infertility and has negative impact on pregnancy rate.

In summary, the association between endometriosis and infertility may be caused a few mechanisms.

Distorted pelvic anatomy: endometriosis could cause pelvic adhesions. These organs can adhere to the uterus, bowel or pelvic wall. This distortion of reproductive organs could cause infertility. if the eggs in the ovaries are damaged by the misplaced tissues egg quantity and quality could be compromised which results ovulation abnormalities which can impair egg release from the ovary and egg pickup after being released; The tubes can be damaged and blocked; ovaries can contain cysts formed from misplaced tissue it also can block sperm entry into the distal tube.

Altered peritoneal environment: Also Altered peritoneal function and impaired endometrium and implantation are also contributing to the infertility. women with endometriosis have increased volume of peritoneal fluid, increased immune cells and concentrations of prostaglandin etc. These may impair egg, sperm, embryo and fallopian tube function.

Altered system immune function: women with endometriosis may have increased antibodies and lymphocytes and this may alter endometrial acceptance to embryo implantation.

Endocrine and ovulatory abnormalities: Women with endometriosis may also present abnormal follicle growth, the luteinized unruptured follicle syndrome, luteal phase dysfunction and premature and multiple LH surges.

Abnormal tubal function: egg capture inhibitor was reported present in peritoneal fluid from women with endometriosis.

Abnormal fertilization and implantation: fertilization and implantation may be impaired in women with endometriosis. Endometrial function may be not normal.

Medications could improve the quality of life for many women with endometriosis; however their contraceptive effects are limited their application. There were many researches showing that acupuncture is effective of releasing pain associated with endometriosis. Acupuncture also stops misplaced tissue growing, regulates period and improves fertility. According to traditional Chinese medicine theory, endometriosis is caused by blood stagnation. Acupuncture improves blood flow; this will release the pain and improve other symptoms.

There was a case report about acupuncture treatment for endometriosis associated infertility from China. 25 patients with endometriosis associated with infertility were treated with acupuncture. After 2 months of treatment, 9 patients achieved pregnancy.

A report in Zhong Guo Zhen Jiu (1996) also studied effectiveness of acupuncture on endometriosis associated with infertility. There were 72 women with endometriosis associated with infertility involved. The acupuncture treatment duration is 3-9 month. 42 women achieved pregnancy. Success rate was 58.33%.

References
Zhou et al (2009) Afr J Tradit Complement Altern Med 6: 494-517
http://www.cnki.com.cn/Article/CJFDTotal-ZGZE602.020.htm
Luiz Fernando et al Rev Assoc Med Bras (2012) 58:607-614

Acupuncture is effective on dysfunctional uterine bleeding and restoring ovulation

As we all know, women have menstrual cycles which occurs as a result of cyclic hormonal changes are usually 21-40 days long, with bleeding duration of 3-7 days and an average blood loss of 20-80 ml. Many women experience some kind of menstrual cycle disturbance; this could be minor disorders or a sign of malignant diseases. Malignant endometrial and cervical disorders include endometrial carcinoma, endometrial heperplasia, cervical cancer and cervical intra-epithelial neoplasia which could present abnormal uterine bleeding.

If a woman is pregnant, vaginal bleeding is abnormal. This often occurs in early pregnancy and is often associated with miscarriage or ectopic pregnancy. Ectopic pregnancy is one of the most severe pregnancy related conditions in women with abnormal uterine bleeding. Threatened miscarriage and miscarriage also present abnormal uterine bleeding.

Benign endometrial and cervical diseases: Fibroids is benign smooth muscle tumors in uterus which is either asymptomatic or presenting abnormal uterine bleeding. Endometrial polyps are a significant cause.

More frequent vaginal bleeding could be caused by pelvic inflammatory disease which is caused by sexually transmitted diseases such as Chlamydia or gonorrhoea. This causes inflammation in the uterus. Endometriosis can also cause more frequent vaginal bleeding. Polycystic ovary syndrome is also the underline causes of abnormal uterine bleeding. Irregular interval of vaginal bleeding could be caused by oral contraceptive pills and perimenopause.

Abnormality presents as duration, interval and amount of the bleeding, if a woman is not pregnant and ovulates regularly.

Very heavy vaginal bleeding: This could be caused by benign conditions including uterine fibroids, endometrial polyps, adenomyosis, intrauterine devices, hypothyroidism, an autoimmune disorders, blood clotting disorders and medications disturbing blood clotting.

Lighter vaginal bleeding could be caused by hyperthoroidism, oral contraceptive pills.

Bleeding between periods could be caused by contraceptive pills, intrauterine device, psychological stress and anticoagulant medications.

If a woman does not ovulate reduction of periods or period blood flow could be seen in some conditions, such as, some chronic conditions and physical and psychological stress, hypothalamus dysfunction, anorexia nervosa, and polycystic ovarian syndrome.

Majority of women with abnormal uterine bleeding do not have structural and histological abnormalities fortunately. Dysfunctional uterine bleeding is not due to certain pelvic disease, complications of pregnancy or systemic illness but mostly related to hormonal dysfunction. These affect 30% of women in reproductive age. Dysfunctional uterine bleeding is a common condition in women in reproductive age. This could be caused by psychological and/or physical stress, malnutrition, or systematic disorders which affect hypathalumic-pituitary-ovarian axis. They present with heavy abnormal uterine bleeding patterns: longer bleeding days, heavy blood loss, more frequent period cycles. In such cases, it is likely associated with aovulations. Changes of normal menstrual cycles are normally caused by disturbances of the hypothalamus-pituitary-ovarian axis. Most cases of anovulatory bleeding are caused by estrogen withdrawal or estrogen breakthrough bleeding. This could present midcycle spotting or intermittent spotting. This also could present irregular or prolonged heavy bleeding. In the case of no ovulation, the uterine endometrium at the presence of estrogen stimulation reaches abnormal heights and lacks structural support and it becomes fragile. The fragile endometrium breaks down and bleeding occurs. The fundamental issue in anovulatory bleeding is that the ovary does not function well causing hormonal imbalance. If a woman with anovulatory bleeding is trying to conceive, she would have difficulty to get pregnant because of anovulation. Improving ovary function is the key to treat anovulatory bleeding.

In Traditional Chinese Medicine (TCM) dysfunctional uterine bleeding can be divided into three types

1. Spleen and kidney yang deficiency, the symptoms include prolonged uterine bleeding, heavy periods, light red without clot, excessive vaginal discharge, tireness, lower back pain, feeling cold, cold hands and feet, diarrhoea, swelling tongue with light white coating, and week and sink pulse.

2. liver and kidney yin deficiency, the symptoms include irregular periods, prolonged uterine bleeding, red blood, dizziness tinnitus, lower backpain, dry mouth, red tongue, week and sink pulse.

3. kidney deficiency and liver stagnation, the symptoms include irregular periods, breast pain, lower back pain, lower tummy pain, excessive vaginal discharge, light tongue and week and sink pulse.

Apart from medication and surgery treatments, acupuncture is an effective treatment for dysfunctional uterine bleeding

Acupuncture could stimulate nerve end to improve ovarian blood circulation. This could improve ovarian function, restore hormonal balance and ovulation and stop abnormal vaginal bleeding and improve fertility.

Zeng et al conducted a controlled trial to investigate effectiveness of acupuncture on dysfunctional uterine bleeding. It was involved in 252 patients. These patients were divided into three groups acupuncture group, Chinese medicine group and conventional medicine group with 84 patients in each group. The result showed that acupuncture has the best effect compared with Chinese medicine and conventional medicine groups. Dr Cheng reported 90 cases of dysfunctional uterine bleeding treated with acupuncture or acupuncture and moxbustion. These women were aged between 16-46, most of them were 25-35. Uterine bleeding days were from 9 days to 65 days. They found that acupuncture and moxibustion are effective treatments for women with dysfunctional uterine bleeding.

References
http://www.acumoxj.com/readlist.asp?id=383
Hickey M et al. Cochrane Database Syst Rev. 2007 Oct 17;(4):CD001895.
http://journal.9med.net/html/qikan/zxyjh/zhzxyzz/20047514/zyzy/20080903023004133_2488.html
http://www.cqvip.com/QK/92077A/200404/9576315.html

Not ovulate to get pregnant ? How? acupuncture can help ovulation.

There are many factors that cause anovulation and here are some common causes of anovulation.

Hypothalamic-pituitary causes

Hypothalamus-pituitary-ovarian-axis dysfunction. This is caused by problems of hypothalamus or pituitary gland in the brain. As a result the hormones are not balanced which does not trigger ovulation and leads to infertility. The reasons that affect hormone balance include stress (see below); the other common causes are excessive exercises and/or underweight.

As we already known that subtle environmental changes may alter the menstrual cycle and cause anovulation. For example, summer camp menstrual disturbances and exam anovulation. Women in emotional stress could have no ovulation. This is temporary situation. If women get out of the stress environment, menstruation and ovulation could be returned. However if this situation is prolonged, anovulation could be persistent. Finding the causes of stress situation and avoiding the causes are the keys for ovulation to return. Many therapies could help reduce stress, such as psychological therapy, yoga and acupuncture etc.

Ovarian causes. If ovary does not respond to FSH and LH, this also causes ovulation problem.

Polycystic ovary syndrome (PCOS). This is commonest cause of anovulation related infertility. It explained 70% of the cases. Women with PCOS have imbalanced hormone levels. This may produce multiple cysts in ovaries, irregular period cycle, anovulation, infertility, acne and excessive hair growth and other symproms.

Premature ovarian failure (POF). In women with POF, their ovaries fail to function properly before menopause occurs. The ovaries don’t respond to FSH and there is no ovulation. They have difficulty to get pregnant.

Treatments that reduce stress can be effective to improve ovulation. Acupuncture helps treating anovulation by stimulating nerve endings and correcting hormonal imbalance. Acupuncture is very effective treatment for anovulation. Acupuncture reduces stress by regulating response to stress and altering stress related chemical substances levels; improves hypothalamus-pituitary-ovarian axis function and regulates blood hormone level. As a consequence, it improves ovulation and pregnancy rate.

Here are some clinical reports about the effectiveness of acupuncture on anovulation.

There was a control trial with acupuncture group and control group (treated with Clomephene). 25 cases in each group were given 6 cycles treatments. And then ovulation and pregnancy rate were compared between the two groups. Ovulation rate is not significantly different between the two groups. The pregnancy rate is higher (44%) in the acupuncture group than in the control group (16%).

There was a case report from a reproductive health institute center in Sichuan in China. They reported the effectiveness of acupuncture on women with anovulation. Ovulation rate was from 70-80% and pregnancy rate was from 40% - 60%.

Recently Yan and Liu summarised some case reports about effectiveness of acupuncture on increasing ovulation. They collected 21 papers which used acupuncture treated anovulation associated infertility.

Here are some typical cases.

Chen et al treated 42 patients with infertility associated with anovulation. 41 of them ovulated.

Kou et al used acupuncture treatment for 50 cases of anovulation associated infertility. 40 of 50 patients achieved pregnancy.

Chang et al used acupuncture for 32 patients with anovulation associated infertility. 9 patients achieved pregnancy during 1-3 month of acupuncture treatment. 22 patients achieved pregnancy over 4 months of acupuncture treatments.

Case report for effectiveness of acupuncture on infertility caused by anovulation

There was a study about effectiveness of acupuncture for infertility without ovulation. There were 50 women with infertility without ovulation. There women were divided into two groups: acupuncture group and control group. Control group was treated with clomiphere and injection of chorionic gonadotropin. The period of treatment was 6 cycles and ovulation rate and pregnancy rate were measured. The results showed that there was no difference in the ovulation rate between the acupuncture group and clomiphere group. However the pregnancy rate in acupuncture group was significantly higher (44%) than that for control group (16%). In addition the score of mucus and endometrial thickness was greater in acupuncture group.

This is a case report on effect of acupuncture treatment of infertility caused by ovulatory problems. 120 patients with infertility caused by ovulatory problems were divided into two groups: acupuncture group and clomiphene control group. 3 treatment cycles were applied. Result showed that similar ovulation rate was observed in both group, but pregnancy rate was higher and abortion rate was lower in acupuncture group compared to control group.

References
Yan and Liu Shanghai J Acu-mox, (2005) 24:40-42 (针灸促排卵临床概况)
Song FJ et al Zhongguo Zhen Jiu (2008) 28:21-23
Jiang and Ding Zhongguo Zhen Jiu (2009) 29:21-4