Infertility is a blanket term which describes the inability to conceive after trying for 12 months. My definition of infertility, however, is not conceiving after a year of timed intercourse. Sperm stays alive in the reproductive tract for between two and four days, so couples who have intercourse for the purpose of conception when their ovulation-predictor-kit indicates “peak” ovulation, are reducing their chances of getting pregnant.

In actuality there is no disease called ‘infertility’. Infertility represents the expression of an underlying pathomechanism which precludes one from conceiving.

Furthermore, infertility can be separated into female-factor and male-factor.

This article will explain many of the various pathomenchanisms which cause or contribute to infertility in Western and traditional Chinese medicine terms and the Chinese medicine approach to intervention.

1. Female Infertility

a. Advanced maternal age.

AMA is a term used to describe ANY female who is thirty-five-years-old or older. Each month starting from the onset of menses, women lose 1001 eggs. One thousand become atretic(they die) and one is ovulated. Women will ovulate between 400 and 500 times in their lifetime.

As a women ages she is constantly losing 1001 eggs per month and so, over time, there is a state reached known as “low ovarian reserve”. What is almost always concomitant with LOR is poor egg quality. Poor egg quality ends up causing infertility or chronic, recurrent miscarriage as the eggs are frequently aneuploidic (chromosomally abnormal).

In order for a woman to menstruate, she MUST have eggs, as the follicles which house the eggs secrete estrogen and when the follicle becomes the corpus luteum, it secretes progesterone. These two “sex” hormones are necessary for menstruation and are responsible for many things including the maturation of the endometrium to allow embryo receptivity. If the woman had no eggs, she’d have minimal to no estrogen or progesterone and thus, wouldn’t menstruate. So, as along as a woman is menstruating, she has a chance to have her egg quality improved.

This patient will typically have a high FSH and a low AMH or she can have a normal FSH with elevated estrogen: this is all abnormal. Conversely, a forty-year-old woman can have completely normal numbers: the same numbers that a twenty-year-old would have and not get pregnant. These numbers are not truly representative of the state of reproductive health.

Age is the predominant factor in an advanced-maternal-age patient, NOT the hormonal picture. Of course, in most cases the hormonal presentation will match the age of the patient.

What does this scenario represent from a traditional Chinese medicine perspective? Kidney essence vacuity. Kidney essence is expressed as sperm, and egg(oocyte). As woman age, their essence becomes depleted and success in conception becomes more and more difficult to achieve.

Of course, there can be additional pieces of the diagnostic puzzle manifest. For example, she may also have liver qi stagnation, or heart-blood-spleen qi vacuity. But it is imperative that the practitioner understands the real root problem…kidney essence vacuity.

So, our patient has been diagnosed with kidney essence vacuity. The treatment principle will be: Fortify the kidneys, nourish essence and facilitate conception.

A good acupuncture prescription might look like this:

Yin tang and ear shenmen (fear and fright damage the kidneys). The use of these points calms the shen, thereby reducing anxiety and/or fear.

Stomach 36 to benefit the stomach and spleen. We want to tonify earth to benefit the kidneys. Why? Because if stomach/spleen qi (earth) is deficient. dampness and phlegm may manifest causing an additional pathology but also causing lack of harmony in the kidneys. Dampness drains downward, so phlegm and damp can end up negatively impacting the lower jiao (think of the PCOS patient).

I like Spleen 6 as it is the crossing point of the Liver, Kidney and Spleen, all organs which can negatively affect kidney function if out of balance.

Kidney 3 to tonify kidney function.

Kidney 11 to tonify kidney function and to benefit the Sea of Blood, the Chongmai, and, it is a local point to the ovaries and uterus.

Stomach 30 is a good point as its local, tonifies the other Sea of Blood (the yangming) and is a crossing point of the Chongmai.

I use zigongxue with every fertility case regardless of the diagnosis. After all, Zigongxue translates into Fetal Palace.

Ren 14 is a good point to drive blood to the uterus via the baomai.

Kid11 is a good point to use to facilitate the flow of essence to the ovaries and uterus via the bao luo.

Ren 6 is a major point used to tonify qi.

Liver 3 is good to use as it facilitates movement of qi within the midst of tonification.

Here is a formula of my own design to treat this patient:

Sijunzitang to(benefit the spleen to facilitate the post heaven source of qi and blood. Blood is stored in the liver and excess blood goes to the kidneys where it is transformed into essence.

add rou cong rong and Fu penzi to directly benefit essence. Use a small dose of chai hu to lift the qi; this helps maintain the health of the spleen qi as the direction of spleen qi is upwards. I always use chai hu when tonifying the spleen.

Use xiang fu to facilitate movement within tonification. And add a small dose, maybe 6gm of Chuan niu xi as a downward guiding herb. Also, the combination of chai hu and chuan niu xi maintain the free flow of qi and blood as one directs qi upwards and one downwards maintaining an endless flow of circulation.

Dang shen

Bai zhu

Fu ling

Zhi gan cao

Rou coung rong

Fu pen zi

Chai hu

Chuan niu xi

Xiang fu

b. Poly cystic Ovarian Syndrome

PCOS is a metabolic as well as an endocrinologic syndrome.

Poly Cystic Ovarian Syndrome (PCOS) is one of the most common metabolic and reproductive disorders among women of reproductive age. Women suffering from PCOS present with a constellation of symptoms associated with menstrual dysfunction and androgen excess, which significantly impacts their quality of life.

They may be at increased risk of multiple morbidities, including obesity, insulin resistance, type II diabetes mellitus, cardiovascular disease (CVD), infertility, cancer, and psychological disorders.

This review summarizes what the literature has so far provided from guidelines to diagnosis of PCOS. It will also present a general overview about the morbidities associated with this disease, specifically with its more severe classic form. Finally, the review will stress on the various aspects of treatment and screening recommendations currently used in the management of this condition. Out of the three diagnostic criteria illustrated below, the Rotterdan Criteria is the most widely accept presently.

Sub-classification of PCOS

➢ Frank or classic polycystic ovary PCOS (chronic anovulation, hyperandrogenism, and polycystic ovaries)

➢ Classic non-polycystic ovary PCOS (chronic anovulation, hyperandrogenism, and normal ovaries)

➢ Non-classic ovulatory PCOS (regular menstrual cycles, hyperandrogenism, and polycystic ovaries)

➢ Non-classic mild or normoandrogenic PCOS (chronic anovulation, normal androgens, and polycystic ovaries.

There is one common thread that runs through most, but not all PCOS patients: phlegm congealing in the lower jiao. As mentioned previously, there can be many additional components to the diagnosis of a particular patient but remember that Phlegm is usually implicated.

When is Phlegm not implicated?

There are some PCOS patients that present with the biologic signs and symptoms of PCOS, but not physical signs, meaning they have a flat line of estrogen, hyperinsulinemia, hirsutism, oligo or amenorrhea, and infertility. This is also known as classic non-polycystic ovary PCOS. So, in a minority of cases, phlegm is not the main issue. A differential diagnosis according to the tenets of TCM must be arrived at for these individuals based on the intake, but again, phlegm or damp will not be part of the diagnosis. Also be aware that 50% of PCOS patients are normomorphic, but even if they are normomorphic and they in fact, have polycystic ovaries, then the main part of the illness is phlegm congelation.

Let’s look at a morbidly obese PCOS patient with Frank or classic polycystic ovary PCOS (chronic anovulation, hyperandrogenism, and polycystic ovaries).

What do we wish to accomplish? Pregnancy? Yes, but pregnancy is the end-goal. You can’t go from infertility to pregnancy without the stepwise approach of individual pattern discrimination, and the appropriate treatment protocol for said pattern. It is by treating the ‘pattern’ that the ‘disease’ is ‘cured’.

Here’s a a possible diagnosis: Spleen and kidney yang vacuity with phlegm-damp congealing and congesting in the lower jiao.

Treatment principle: Warm the spleen and kidney yang, dry damp, scatter phlegm, regulate the menses and facilitate conception.

Acupuncture protocol

Large Intestine 4

Liver 3

Ren 9

Ren 6

Ren 4

Zigongxue

Kidney 11

Kidney 3

Stomach 30

Stomach 36

Stomach 40

Spleen 8

Spleen 9

Spleen 6

Du20

Kidney 1

Herbal medicine formula

Dang shen

Bai zhu

Fu ling

Gan cao

Wa leng zi

Chai hu

Chuan niu xi

Cu chao xiang fu

Fu zi

Bu gu zhi

Yi mu cao

C. Endometriosis

Endometriosis is a confounding disease thought to be a disease of menstruating women. This is false. There are cases of pre-pubescent girls that have been diagnosed with endometriosis. There have been cases of men who have had endometriosis. But generally, endometriosis is most prevalent amongst menstruating women.

There is no consensus on the etiology of endometriosis.

“Endometriosis is a disease in which endometrial glands and stroma implant and grow in areas outside the uterus. The disease has a multi-factorial etiology including genetic and environmental factors. Exposure to ovarian hormones appears to be essential. Estrogens stimulate ectopic endometrium growth and aberrations in estrogen signaling have been associated with the disease. Caucasians appear to be more likely to suffer from endometriosis than African Americans or Asians. There is also an increased prevalence in taller women and those with a lower BMI. Genetic factors contribute to approximately 51% of endometriosis risk. Patients with an affected first-degree relative have an approximate 7 to 10-fold increased risk of developing endometriosis.

The prevalence of endometriosis ranges from 2-50% of reproductive aged women. The morbidity associated from endometriosis is great, as it can cause both chronic pelvic pain and infertility. In women with infertility, the prevalence ranges from 20-50%. Endometriosis is present in 71-87% of women with chronic pelvic pain.

A multidisciplinary approach is often required for the diagnosis and management of this disease. In women with pelvic pain and suspected endometriosis, first line treatment would be non-steroidal anti-inflammatory medications with/without oral contraceptives or progestins.

In the treatment of infertility associated with endometriosis, the age, history, health status, physical exam, and wishes concerning treatment should be weighed. There are certain situations where surgery may be indicated for the treatment of infertility associated with endometriosis. Controlled ovarian stimulation with IUI or IVF is often indicated.

Classically, three theories exist to explain the etiology of endometriosis; 1) Sampson’s theory, 2) Meyer’s theory, and 3) Halban’s theory. The most often quoted theory, and to date the one supported by the most evidence, is Sampson’s theory of transplantation and implantation. This theory stemmed from observations made during surgeries in the 1920’s that many women shed endometrial debris through their fallopian tubes into the peritoneum during menstruation. Not only has viable endometrial tissue been found in the fallopian tubes and peritoneal fluid of women, but in humans and other animals, endometrial tissue will grow if placed ectopically. Further supporting this theory, endometriosis seems to occur most commonly in the gravitationally dependent parts of the pelvis. Finally, the incidence of endometriosis is significantly increased in patients with mullerian anomalies or genital tract obstructions, both which increase the likelihood of retrograde flow. One problem with this theory is that retrograde menstruation has been shown in 76-90% of menstruating women, which is much higher than the prevalence of endometriosis. This discrepancy suggests that additional factors beyond the presence of ectopic tissue are needed to establish the disease, such as the amount of endometrial debris that reaches the peritoneal cavity, the immunocompetency of the woman to clear the debris, and the molecular abnormalities/properties inherent in the ectopic tissue. Meyer’s theory suggests that metaplasia of the coelomic epithelium is the origin of endometriosis. This theory is logical, as cells from both the peritoneum and endometrium are derived from a common embryological precursor: the coelomic cell. However, this has been a difficult theory to support scientifically. If this postulate were correct, one would expect much higher rates of pleural endometriosis than are observed.

Halban’s theory is one that suggests that distant lesions are established by the hematogenous or lymphogenous spread of viable endometrial cells. Although this metastatic theory explains rare endometriotic lesions in the brain or lung, it does not explain the gravitationally dependent location of most foci of endometriosis. Sampson’s transplantation and implantation theory are the most widely accepted, but most researchers agree that it grossly simplifies the disease process. Whilst retrograde menstruation can transplant tissue fragments into the peritoneal cavity, the cells themselves must escape apoptosis, adhere to the underlying peritoneum, degrade the underlying extracellular matrix, generate a new vascular supply, and evade the immune surveillance system in order to survive. Clear molecular differences exist between endometriotic lesions and eutopic endometrium. Secondary to the inflammation associated with endometriosis, there are increased levels of prostaglandins, chemokines, and cytokines, such as interleukin-1ß, intlerleukins-1, 6, 8 and tumor necrosis factor (TNF), which are thought to enhance the adhesion of endometriotic implants to the peritoneal surface. These are associated with overproduction of prostaglandins, cytokines, and chemokines. Proteolytic membrane metalloproteinases, also increased in endometriosis, promote implantation. Angiogenesis and apoptosis are also altered in endometriosis in favor of survival of the implant. Granulocytes, macrophages, and natural killer cells are attracted by the increased monocyte chemoattractant protein 1, interleukin-8, and RANTES (regulated upon activation normal T-cell expressed and secreted), present in endometriosis. These inflammatory mediators accumulate in endometriotic tissue by autoregulatory positive feedback loops (16). Erythrocyte breakdown from endometriotic lesions is internalized by macrophages and the non-protein-bound catalytic iron increases the production of reactive oxygen species, thereby perpetuating peritoneal damage and inflammation. Studies have found no association between the oxidative stress and antioxidants such as Vitamins A and E (17), but the association between Vitamin D and endometriosis is more complex. Several studies suggest a role for Vitamin D and its metabolites as local autocrine and paracrine agents involved in endometriosis etiology and pathology, but the exact mechanism has yet to be elucidated.

While steroidogenic factor 1 (SF1) is present in ectopic endometrial tissue, it is not found in the eutopic endometrium. SF1 is involved in estradiol synthesis. The increased amount of estradiol seen in the peritoneal fluid of patients with endometriosis increases local cyclo-oxygenase -2 (COX-2) activity, resulting in stimulation of prostaglandin E2 formation, which upregulates aromatase activity, resulting in additional estradiol to perpetuate the symptoms and lesions present in endometriosis. There is elevated expression of both estrogen receptor α and estrogen receptor ß leading to a downregulation of progesterone receptors, ultimately causing the characteristic hormonal profile seen in endometriosis.”

Now, lets talk TCM. In most Chinese medicine books, the diagnosis for endometriosis is incorrect. The common diagnosis is “stagnation of qi and stasis of blood”.

The end-stage of endometriosis is only when “stagnation of qi and stasis of blood” is manifest. Essentially “stagnation of qi and stasis of blood” is the “branch”. The “root” or etiology’ of endometriosis is ‘rebellious qi and blood with internal heat brewing’. The concept is simple: endometriosis is, at the end of the day, a disease in which the qi and blood of the uterus rebel. Without ‘rebellious qi and blood, how would endometrial tissue travel from the uterus to the cul-du-sac or the ovaries or the tubes or the nose or the diaphragm? Why must “internal heat brewing” always a part of the TCM pattern-of-disharmony of endometriosis? Because endometriosis is a ‘pro-inflammatory-cytokine’ disease. This means that inflammation is always a part of the scenario of endometriosis. If your endometriosis patient comes in with a complaint of endometriosis and her tongue is swollen with a white coat and the pulse is slow, you must disregard the tongue and pulse findings. Tongue and pulse are good tools to ‘corroborate’ a diagnosis but should not be used dogmatically to do so.

Also, you will only see patients who have endo after they have a diagnostic and therapeutic laparoscopy; otherwise how would you know they have endometriosis? There is one way to diagnose some patients with endometriosis even without a laparoscopy; that is when the patient has an endometrioma which is essentially an ovarian cyst derived from endometriotic cells.

This is observable via the trans-vaginal ultrasound examination. Ultrasound, however, cannot reveal if endometriosis is in other areas of the pelvic cavity. So, even if an endometrioma is observed, a subsequent laparoscopy must ensue to rule-out other possible locations of endometriosis for eradication.

Why would a patient present to you with pelvic pain or infertility after a laparoscopy whereupon endometriosis was lysed? Because not all endometriosis is visually identifiable; some endometriotic lesions look exactly like normal tissue. Therefore, it is not uncommon for some endometriosis to be left behind. So, your job as an acupuncturist is not to cure endometriosis, but to downbear rebellious qi and blood, move qi and blood, resolve stagnation and transform stasis and clear heat in the uterus. This type of treatment may, at best, resolve ‘heat’ or, inflammation, thereby making the uterus more amenable to a normal implantation.

Acupuncture protocol

Liver 2

Liver 3

Liver 5

Liver 8

Kidney 2

Kidney 11

Kidney 3

Du 20

Kidney 1

Stomach 36

Ren6

Ren 3

Stomach 30

Spleen 6

Large Intestine 4

Ren 17

Kidney 1

Herbal medicine protocol

Long gu

Dai zhe shi

Yan huo suo

Chuan lian zi

Xiang fu

Dan shen

Chuan niu xi

Chai hu

Dang shen

Bai zhu

Fu ling

Zhi gan cao

Bai shao

This formula downbears qi and blood, stops pain, clears heat and tonifies the qi. The main purpose of this formula is to clear heat and stop pain from residual endometriosis.

2. Male Factor

a. Low Sperm Count

Often, low sperm count is idiopathic. Stress, environmental toxins and heat can all manifest in low sperm count as well as other sperm pathologies. Heavy drinking by the male can increase estrogen levels, thereby causing a reduction in sperm production. We are not going to include genetic factors such as micro deletion of the y chromosome in this paper. Nor will we include physical issues such as varicocele. These issues are better left for donor sperm (unless it’s a ‘minor’ varicocele’, in which case acupuncture and herbs may help, status-post varicocelectomy.)

Within Normal Limits

The “normal Spermatozoa” refers to morphology

The following can result in various sperm anomalies:

1. Stagnation of qi and stasis of blood preventing blood flow to the testes.

2. Liver qi stagnation transforming heat.

3. Heat from Kidney yin vacuity, liver yin vacuity, damp-heat pouring downwards.

4. Essence vacuity

Let’s start with stagnation of qi and stasis of blood preventing blood flow to the testes.

Treatment principle: Sooth the liver, quicken the qi and resolve stagnation, invigorate blood, transform stasis and increase sperm count.

Acupuncture protocol

Large Intestine 4

Liver 3

Du 20

Liver 5

Liver 3

Stomach 36

Yintang

Ear Shenmen

Ren 9

Ren 6

Ren 3

Stomach 30

Spleen 6

Stomach 36

Liver 5

Herbal Medicine Formula

Cu chao xiang fu

Di long

Chai hu

Chuan niu xi

Zhi gan cao

Liver qi stagnation transforming heat (minor varicocele)

Herbal Medicine protocol

Cu chao xiang fu

Ju hua

Bo he

Gan cao

Chai hu.

Chuan niu xi

Chai hu

Acupuncture Protocol

Liver 2

Liver 3

Liver 5

Liver 8

Kidney 2

Kidney 11

Kidney 3

Stomach 36

Gallbladder 43

5. Heat from Kidney yin vacuity

6. Liver yin vacuity

7. Damp-heat pouring downwards

Heat from Kidney yin vacuity (advanced paternal age)

This can manifest from essence vacuity as essence is the substrate for yin.

This is typically seen in men over fifty-years-old

Treatment principle: Forty the kidneys, benefit essence, tonify yin, clear heat and improve sperm parameters.

Acupuncture Protocol

Ren 2

Ren 9

Kidney 2

Kidney 3

Stomach 36

Kidney 11

Large intestine 4

Liver 3

Herbal medicine protocol

Zhi mu

Nu zhen zi

Rou cong rong

Xiang fu

Ba ji tian

Liver yin vacuity

This, often concomitant with kidney yin vacuity, leads to or can lead to hypertension.

Acupuncture Protocol

Ren 2

Ren 9

Kidney 2

Kidney 3

Stomach 36

Kidney 11

Large intestine 4

Liver 2

Gallbladder 43

Kidney 1

Herbal medicine protocol

Zhi mu

Nu zhen zi

Mu li

Xiang fu

Long gu

Ci shi

“Men suffering from hypertension or high blood pressure tend to have poorer sperm quality, and they usually have one or more semen abnormalities. A 2017 study, for instance, revealed that men with high blood pressure had a much lower semen volume compared to men who didn’t have hypertension.

Sperm motility in hypertensive men was also lower at 41%, whereas men who had normal blood pressure had an average of 47%. Moreover, the sperm concentration and total motile sperm count of hypertensive men were also significantly lower.”

The kidneys store essence, which, in men, is manifested as sperm. In the milieu of kidney yin vacuity, or, sometimes, kidney essence vacuity heat will prevail. Heat kills sperm.

Damp-heat pouring downwards (infection)

This is typically resultant from a STD or other infection. This pathology can also manifest from long term damp and phlegm congesting and congealing and transforming heat. If this is, indeed, due to an infection this can be treated with antibiotics. If its due to damp and phlegm congesting and congealing and transforming heat then one must dry damp, scatter phlegm, clear heat and improve sperm parameters. From the perspective of TCM, the formula that comes to mind is long dan xia gan tang. Obviously, adjustments to this formula must be made based upon the patient and their complete presenting signs and symptoms.

Acupuncture protocol

Spleen 9

Stomach 40

Ren 6

Ren17

Stomach 36

Liver 2

Gallbladder 43

Ren 9

Ren 2

Kidney 1

Ren 12

Liver 13

b. Sperm DNA Fragmentation

DNA fragmentation is the term used to denote when the DNA within the sperm contains breaks. Damage to your DNA can occur during sperm production or while it is being stored in your body. If sperm DNA is badly damaged, success at every fertility checkpoint is impaired.

These are the DNA Fragmentation parameters:

0-15% =good fertility outcome; 15-29% = good to fair fertility outcomes; >30% = poor fertility outcomes.

Typically, though not always, sperm DNA fragmentation happens as a result of the sperm being exposed to reactive-oxidative species causing the release of free radicals.

The treatment of free radicals is with antioxidants. Interestingly, the testes contain more free radicals than anywhere else in the body, but they also contain the highest levels of antioxidants in the body. A pathologic state that may ensue is when ROS overwhelms a reduced quantity of TAC (total antioxidant capacity). This is one way in which sperm in all of its parameters may get worse.

“Almost 50% of all cases of infertility may be associated with a male factor. A semen analysis that measures sperm concentration, motility and morphology has classically been used as the gold standard test for determining a man’s fertility. However, this test does not provide any information about the genetic constitution of the sperm, which is essential for normal embryo development.

Thus, a high level of DNA damage in sperm cells may represent a cause of male infertility which conventional examinations cannot detect.

Sperm DNA fragmentation is significantly higher in infertile men. While men with poor sperm parameters are more likely to have high sperm DNA fragmentation, high sperm DNA fragmentation is also found in men with normal semen parameters who may be diagnosed with unexplained infertility.

It is my contention that a “normal” semen analysis should include a sperm-DNA=fragmentation-assay. This would shed light on multitudinous cases on ‘idiopathic’ infertility.

SPERM DNA AND EMBRYO DEVELOPMENT

Sperm with high DNA damage will contribute to nuclear instability in the embryo, resulting in arrested development, failed implantation and a higher miscarriage rate 2-4. High sperm DNA fragmentation is more likely to affect embryos from day two of development once the paternal genome is switched on. There is some evidence to suggest that DNA damage in the embryo could result in cell degeneration and gene mutations, leading to abnormalities in the offspring and an increased susceptibility to childhood cancers4,5

SPERM DNA, PREGNANCY AND MISCARRIAGE

There is considerable evidence to show that the chances of a successful pregnancy are significantly reduced in couples where the male partner has a high percentage of sperm with fragmented DNA. Several large systematic reviews and meta-analyses have revealed that high sperm DNA fragmentation is associated with reduced pregnancy rates and live birth rates following natural or assisted conception, as well as an increased risk of miscarriage6-9. A recent systematic review and meta-analysis showed a significant elevation in sperm DNA fragmentation levels in partners of women experiencing recurrent pregnancy loss following spontaneous conception10. Overall the results of these studies lend support for the value of testing for sperm DNA fragmentation to identify possible causes for unexplained infertility, failed IVF treatment cycles or recurrent miscarriage. Current European Society for Human Reproduction and Embryology (ESHRE 2017) guidelines recommend sperm DNA fragmentation testing for men whose partners experience recurrent pregnancy loss.”

In TCM terms, this is detriment to kidney essence and must be treated as such. Herbal medicine works wonders for this malady. I recommend that the patient take antioxidants such as Vitamin E, Vitamin C, Co-q10, Ubiquinol, etc. Of course, every patient must be treated according to their pattern of disharmony but, I have found a particular formula that frequently reduces sperm DNA fragmentation indexes significantly. The formula is Zan Yu Dan.

I find that in these cases acupuncture is of minimal benefit, but herbs often have a dramatic effect on improving sperm quality in the patient with SDF.

Stress and its effect on sperm

“According to the American Society for Reproductive Medicine, infertility affects men and women equally, and semen quality is a key indicator of male fertility.

"Men who feel stressed are more likely to have lower concentrations of sperm in their ejaculate, and the sperm they have are more likely to be misshapen or have impaired motility," says senior author Pam Factor-Litvak, PhD, associate professor of Epidemiology at the Mailman School of Public Health. "These deficits could be associated with fertility problems."

The researchers studied 193 men, ages 38 to 49, enrolled in the Study of the Environment and Reproduction at the Kaiser Foundation Health Plan in Oakland, California, between 2005 and 2008. The men completed tests to measure work and life stress on subjective scale (how they felt overall) and objective scale (life events behind the stress). They also provided semen samples. Technicians at the University of California, Davis, used standard methods employed in fertility testing to assess the samples for semen concentration, and sperm appearance and motility.

Measured subjectively or objectively, life stress degraded semen quality, even after accounting for men's concerns about their fertility, their history of reproductive health problems, or their other health issues. Workplace stress was not a factor; however, the researchers say it may still affect reproductive health since men with job strain had diminished levels of testosterone. Being without a job did not improve matters. Unemployed men had sperm of lower quality than employed men, regardless of how stressed they were.

It is not fully understood how stress affects semen quality. It may trigger the release of steroid hormones called glucocorticoids, which in turn could blunt levels of testosterone and sperm production. Another possibility is oxidative stress, which has been shown to affect semen quality and fertility.

"Stress has long been identified as having an influence on health. Our research suggests that men's reproductive health may also be affected by their social environment," says Teresa Janevic, PhD, the study's first author and an assistant professor at the Rutgers School of Public Health.

While several previous studies have examined the link between stress and semen quality, the current paper is the first to look at subjective and objective measures of stress and find associations with semen concentration, and sperm appearance and motility.”

The acupuncture protocol that I use on men with low sperm count who are experiencing high levels of stress(not including sperm DNA fragmentation) may look something like this:

Large Intestine 4

Liver 3

Ren 2

Stomach 30

Kidney 11

Kidney 3

Stomach 36

Yintang

Ear Shenmen

Du20

Ht7 and PC6 may also be employed to help reduce stress. This prescription moves the qi, tonifies the qi, and calms the shen.

Again, a differential diagnosis according to TCM must be arrived at but, generally speaking, ding zhi wan should be part of the overall formula to help resolve anxiety, trepidation and fear. As one can imagine, a man going through infertility is probably experiencing all of these emotions.

Stress and its effect on the fertility quotient of female patients

There are many acupuncturists who attribute stress as a contributing cause of female infertility, or at least part of the cause of infertility. I’ve always doubted this postulate. When watching any news coverage on a war-torn country, one typically sees: bombed out buildings, men shooting guns, women crying and screaming and little babies and little kids running around crying. Where did all these new-borns and young kids come from? Intercourse in the midst of the most stressful environment possible. These women, in war torn countries, can and do get pregnant. Perhaps stress affects some women negatively from the perspective of fecundity but not all.

Idiopathic Infertility

When a thirty-year old, healthy couple presents for an infertility evaluation and they’ve already been seen by a reproductive endocrinologist for an evaluation and there is no pathology found, remember, there is always a presenting pathology. It has just not been diagnosed. This occurs for two main reasons:

1. Failure on the part of the physician to do a proper and thorough evaluation or

2. A diagnostic tool or protocol is not yet extant which can diagnose every potential pathology which exists.

It is our job to understand which tests should be run by the doctor. This way we can recommend testing for which thus far, the doctor has not done.

Secondly, we must be good TCM diagnosticians so we can, based upon TCM logic, arrive at a pattern of disharmony and a treatment plan.

Western Medical Testing

A. Hysterosalpingogram

This is a test whereupon dye is pushed through the fallopian tubes while the pelvis is x-rayed. This test determines whether or not the fallopian tubes are patent and functional. Tubes can be blocked, scarred or present with hydrosalpinx. If a tube has a hydrosalpinx the best approach is a salpingectomy as the fluid in the hydrosalpinx is toxic and can destroy the embryo. Removing a tube presents no reduction in fecundity. If the left tube is removed and ovulation occurs via the left ovary, via peristalsis of the right tube, the egg ovulated from the left ovary will be picked up by the right tube. Of course, this scenario is bilateral. If the tubes are blocked with a mucous plug, it is often the hysterosalpingogram that can unblock the tube. If a both tubes are scarred (PID, endometriosis), the only answer is IVF.

This doesn’t preclude the use of acupuncture and herbal medicine as there role is to improve egg, lining or sperm quality.

B. Fluid Ultrasound (aka saline sonohysterogram)

This is a test which can visualize small polyps (uterine growths which are generally benign. They obfuscate surface area thus interfering with embryo implantation). Larger polyps are often visualized via the Hysterosalpingogram. Some doctors say they can see polyps via a Hysterosalpingogram and don’t want to do the fluid ultrasound test. This is a grave error as typically, smaller polyps are not visualized via a hysterosalpingogram, only via a fluid ultrasound. Polyps are removed with a hysteroscope. The procedure is known as a polypectomy.

C. Ureaplasma urylitica

“Ureaplasma is present in the body of many healthy men and women, most often found in the cervix and vagina of women and the urethra of men. Most often, the bacteria do not cause any problems. However, in other people, the condition is thought to cause a variety of painful or problematic symptoms, including:

Pelvic pain

Infertility

Miscarriage or recurrent miscarriage

Pain with urination

Recurrent yeast infections, discolored or foul-smelling vaginal discharge

Discharge from the penis

Ureaplasma is spread during sexual activities and transmission can be genital to genital or oral to genital. Pregnant women can also spread ureaplasma to an unborn infant.

If testing for ureaplasma is positive, both the individual and his or her sexual partner will be prescribed a round of antibiotics specific to treating ureaplasma. (usually doxycycline)The condition and any resulting symptoms should clear up with appropriate usage.”

Treating Pregnant Patients With Herbs

If a patient has a sub-chorionic-hematoma, this can lead to (and often does) miscarriage. In this case, the ever-growing blood clot will overcome the developing embryo cutting it off from a normal and efficacious blood supply. In this case it is appropriate to use shao fu zhu yu tang. Many practitioners would not opt for invigorating blood in a pregnant patient. This is usually due to the lack of experience on the part of the practitioner. Remember this: if there is pathology, your correct treatment will only treat the pathology and not harm the host.

Treating pregnant patients with abdominal acupuncture

I treat ALL pregnant patients for 13 weeks after pregnancy is confirmed using the following points, some of which are abdominal.

Ren 12

Liver 13

Zigongxue

Ren 3

Kidney 11

Stomach 30

Gallbladder 26

Du20

This acupuncture protocol harmonizes the zang-fu, raises the qi, stimulates blood flow to the uterus (placenta), and ‘contains’ the fetus (Gallbladder 26).

In 23 years of practice I’ve never caused a miscarriage by using these points.

Some general notes for acupuncturists.

1. Every one of your patients who is being treated for infertility or chronic, recurrent- miscarriage must be under the care of a reproductive endocrinologist. I won’t treat a patient who is not.

2. Know what you can’t treat.

3. Learn Western reproductive medicine to the extent that you can. It will help you with your cases.

4. Never be afraid to treat pathology, even in a pregnant woman. This can save the pregnancy, where being conservative in treatment may be the cause of miscarriage.

Case Review

The patient is a 38 year-old, G4P0, female physician who gets pregnant after several months of treatment with acupuncture, herbs and donor sperm. The sperm donor is ‘proven’. She chronically miscarries. She was diagnosed with endometritis and was given antibiotics. The endometritis returned only to facilitate another miscarriage. Endometritis, from a TCM perspective is ‘heat in the uterus’. Since she proved to be refractory to antibiotics, I prescribed a formula that many would not have used. Why? Because it’s a ‘cold’ formula. And we’ve all been falsely taught that it is a poor medical decision to give a pregnant patient cold herbs. “The uterus must always be warm” is the dogma.

TCM Diagnosis: Heat in the lower jiao

Treatment principle: Clear heat, resolve stagnation, facilitate implantation, and prevent miscarriage.

Huang lian, 6

Huang bai, 9

Sheng jiang, 6

Xiang fu, 9

Bai shao, 15

Zhi gan cao, 6

Huang qi, 15

This patient conceived and miscarried consistently between weeks four and five. She is now seven weeks pregnant for the first time. I used ‘cold’ herbs to treat the internal heat (endometritis) but added warming herbs to balance the formula. Do not be afraid to treat pathology. This is a pearl.

Mike Berkley, Licensed Acupuncturist in Manhattan

23 Years of Helping Couples in New York

Founder and director of The Berkley Center for Reproductive Wellness, Mike Berkley is licensed and Board Certified in Acupuncture in New York State and certified in Chinese herbology by the National Certification Commission for Acupuncture and Oriental Medicine.

Mike graduated from The Pacific College of Oriental Medicine in New York in 1996, and he has been treating reproductive disorders since then. Mike is the first acupuncturist/herbalist in the United States to work exclusively in the field of reproductive medicine.

Citations below:

El Hayek, Samer, Lynn Bitar, Layal H. Hamdar, Fadi G. Mirza, and Georges Daoud. “Poly Cystic Ovarian Syndrome: An Updated Overview.” Frontiers in Physiology 7 (April 5, 2016). https://doi.org/10.3389/fphys.2016.00124.

Carpinello, Olivia J., Lauren W. Sundheimer, Connie E. Alford, Robert N. Taylor, and Alan H. DeCherney. “Endometriosis.” In Endotext, edited by Kenneth R. Feingold, Bradley Anawalt, Alison Boyce, George Chrousos, Kathleen Dungan, Ashley Grossman, Jerome M. Hershman, et al. South Dartmouth (MA): MDText.com, Inc., 2000. http://www.ncbi.nlm.nih.gov/books/NBK278996/.

Glenn. “Does High Blood Pressure Affect Sperm Count?” Male UltraCore Blog (blog), August 11, 2019. https://www.maleultracore.com/blog/does-high-bloo...

Evgeni E, Charalabopoulos K, Asimakopoulos B (2014) Human sperm DNA fragmentation and its correlation with conventional semen parameters J Reprod Infertil 15(1):2-14.

Borges E Jr, Zanetti BF, Setti AS, Braga DPAF, Provenza RR, Iaconelli A Jr(2019) Sperm DNA fragmentation is correlated with poor embryo development, lower implantation rate, and higher miscarriage rate in reproductive cycles of non-male factor infertility. Fertil Steril. 2019 Jun 11. pii: S0015-0282(19)30408-X. doi: 10.1016/j.fertnstert.2019.04.029. [Epub ahead of print] PubMed PMID: 31200969.

Agarwal A, Panner Selvam MK, Baskaran S, Cho CL (2019) Sperm DNA damage and its impact on male reproductive health: a critical review for clinicians, reproductive professionals and researchers. Expert Rev Mol Diagn 19(6):443-457.

Lewis SE, John Aitken R, Conner SJ, Iuliis GD, Evenson DP, Henkel R, Giwercman A, Gharagozloo P (2013) The impact of sperm DNA damage in assisted conception and beyond: recent advances in diagnosis and treatment. Reprod Biomed Online 27(4):325-37.

Gavriliouk D, Aitken R (2015) Damage to Sperm DNA Mediated by Reactive Oxygen Species: Its impact on Human Reproduction and the Health Trajectory of Offspring. Adv Exp Med Biol 868:23-47.

Robinson L, Gallos ID, Conner SJ, Rjkhowa M, Miller D, Lewis S, Kirkman-Brown J and Coomarasamy A (2012) The effect of sperm DNA fragmentation on miscarriage rates: a systematic review and meta-analysis Hum. Reprod. 27 (10): 2908-2917.

Zhao J, Zhang Q, Wang Y, Li Y (2014) Whether sperm deoxyribonucleic acid fragmentation has an effect on pregnancy and miscarriage after in vitro fertilization/intracytoplasmic sperm injection: a systematic review and meta-analysis. Fertil Steril 102(4):998-1005.

Osman A, Alsomait H, Seshadri S, El-Toukhy T, Khalaf Y (2015) The effect of sperm DNA fragmentation on live birth rate after IVF or ICSI: a systematic review and meta-analysis.. Reprod Biomed Online 30 (2):120-7.

Simon L, Zini A, Dyachenko A, Ciampi A, Carrell DT (2017) A systematic review and meta-analysis to determine the effect of sperm DNA damage on in vitro fertilization and intracytoplasmic sperm injection outcomeAsian Journal of Andrology 19: 80–90.

Tan J, Taskin O, Albert A, Bedaiwy MA. (2019) Association between sperm DNA fragmentation and idiopathic recurrent pregnancy loss: a systematic review and meta-analysis. Reprod Biomed Online. 38(6):951-960.

Evenson D, Gharagozloo P, Aitken RJ (2017) Sperm Chromatin Structure Assay (SCSA®): The Clinical Utility of Measuring Sperm DNA Damage and its Potential Improvement with Supplemental Antioxidants. JSM In vitro Fertil 2(1): 1008.

Cho CL, Agarwal A, Majzoub A, Esteves SC (2017) Clinical utility of sperm DNA fragmentation testing: concise practice recommendations. Transl Androl Urol. 6(Suppl 4):S366-S373.

Sakkas D, Alvarez JG (2010) Sperm DNA fragmentation: mechanisms of origin, impact on reproductive outcome, and analysis. Fertility and Sterility 93(4): 1027-36.

Wright C, Milne S, Leeson H (2014) Sperm DNA damage caused by oxidative stress: modifiable clinical, lifestyle and nutritional factors in male infertility. Reprod Biomed Online 28:684-703.

Bisht S, Dada R (2017) Oxidative stress: Major executioner in disease pathology, role in sperm DNA damage and preventive strategies. Front Biosci (Schol Ed.) 9:420-447.

Ribas-Maynou J, Benet J.(2019) Single and Double Strand Sperm DNA Damage: Different Reproductive Effects on Male Fertility. Genes (Basel). 31;10(2). pii: E105. doi: 10.3390/genes10020105. Review.

Evenson DP (2016) The Sperm Chromatin Structure Assay (SCSA(®)) and other sperm DNA fragmentation tests for evaluation of sperm nuclear DNA integrity as related to fertility. Animal Reprod Sci 169:56-75.

Yan S, Shabbir M, Yap T, Homa S, Ramsay J, McEleny K, Minhas S (2019) Should the current guidelines for the treatment of varicoceles in infertile men be re-evaluated? Human Fertil 23: 1-15.

Moskovtsev SI, Lecker I, Mullen JB, Jarvi K, Willis J, White J, Lo KC (2009) Cause-specific treatment in patients with high sperm DNA damage resulted in significant DNA improvement. Syst Biol Reprod Med. 55(2):109-15.

Showell MG, Mackenzie-Proctor R, Brown J, Yazdani A, Stankiewicz MT, Hart RJ (2014) Antioxidants for male subfertility. Cochrane Database Syst Rev 12, CD007411–CD007411.

Santi D, Spaggiari G, Simoni M (2018). Sperm DNA fragmentation index as a promising predictive tool for male infertility diagnosis and treatment management - meta-analyses. Reprod Biomed Online. 37(3):315-326.

22. Awaga HA, Bosdou JK, Goulis DG, Chatzimeletiou K, Salem M, Roshdy S, Grimbizis G, Tarlatzis BC, Kolibianakis EM (2018) Testicular versus ejaculated spermatozoa forICSI in patients without azoospermia: A systematic review. Reprod Biomed Online. 37(5):573-580.

23. Esteves SC, Roque M, Bradley CK, Garrido N (2017) Reproductive outcomes of testicular versus ejaculated sperm for intracytoplasmic sperm injection among men with high levels of DNA fragmentation in semen: systematic review and meta-analysis. Fertil Steril 108(3):456-467.

24. Oleszczuk K, Giwercman A, Bungum M (2016) Sperm chromatin structure assay in prediction of in vitro fertilization outcome Andrology4: 290–296.

25. Chen Q, Zhao JY, Xue X, Zhu GX (2019). The association between sperm DNA fragmentation and reproductive outcomes following intrauterine insemination, a meta analysis. Reprod Toxicol 86:50-55.

ScienceDaily. “Stress Degrades Sperm Quality, Study Shows.” Accessed December 3, 2019. https://www.sciencedaily.com/releases/2014/05/140...

FertilitySmarts. “What Is Ureaplasma? - Definition from Fertilitysmarts.” Accessed November 30, 2019. https://www.fertilitysmarts.com/definition/576/ureaplasma-fertility.