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The Verdict on Alternative Treatments and Fertility

More and more infertile couples are turning to holistic techniques to increase their odds of conception and to cope with the stresses of trying to conceive. There is increasing evidence of the effectiveness of alternative medical approaches. Learn more from A Baby at Last!: The Couple’s Complete Guide to Getting Pregnant — from Cutting-Edge Treatments to Commonsense Wisdom, by Weill Cornell Medical Center physicians Zev Rosenwaks, M.D., and Marc Goldstein, M.D., along with Mark L. Fuerst.

Some fertility clinics, including Weill Cornell, recommend that couples introduce yoga, relaxation, and nutrition into their fertility treatment plans or, in difficult cases, try acupuncture in addition to assisted reproductive technologies (ART).

We recently evaluated the utilization of complementary alternative modalities (CAM) among three hundred of our female patients undergoing infertility treatment. This represents one of the first documentations of the prevalence of CAM usage in infertility patients. The women, average age

thirty-seven, had an average duration of infertility ranging from one to five years. The results of anonymous questionnaires showed that they used a range of CAM treatments, primarily acupuncture but also herbal therapy, yoga, massage, special diets, vitamins, stress reduction, and meditation. About half of the women who completed the survey reported using CAM while undergoing ART.

More than 90 percent of the women reported benefits, including stress reduction, improved mood, empowerment, and perceived improved responses, and about three quarters of those who had never used CAM for infertility said they would use it in a future treatment. Despite conflicting reports on the efficacy of CAM, future studies on the effectiveness of these treatments seem warranted.

Traditional Chinese medicine (TCM) believes that both partners should be as healthy as possible at the time of conception to ensure that they have the best possible chance at conceiving. Additionally, TCM aims to improve the overall health of the mother- and father-to-be to decrease the risk of

miscarriage. TCM practitioners who work with fertility patients incorporate acupuncture, herbs, and meditative relaxation exercises such as tai chi and qi gong to help balance the body and mind to improve conception rates.

A hectic Western lifestyle may influence fertility through pervasive stress. Studies show that women who participate in mind-body interventions, including yoga, meditation, and visualization, as well as cognitive behavioral therapy, can reduce stress and possibly improve their pregnancy rates. It should be emphasized that it has been difficult to prove that any of these holistic approaches definitely improve your chances of achieving a pregnancy. They are better thought of as adjuncts to fertility treatments.

Traditional Chinese Medicine

TCM practitioners view infertility as a symptom of imbalance, and the goal of therapy is to cultivate balance in body and mind, strengthen the immune system, and create harmony in all areas of life.

One of the principles of TCM is that there are many meridians, or energy pathways through the body, that need to be in balance for good health. Any disruption in these patterns of energy flow, called qi, may lead to disease. For a woman, the goal of therapy is to regulate the menstrual cycle

and strengthen her body. TCM practitioners determine which meridians may create problems with fertility or pose a threat to a pregnancy. For a man, the TCM practitioner will ask a series of questions to assess areas that need to be strengthened in order to increase his sperm count and sperm quality.

Like fertility specialists, TCM practitioners first undertake an individual consultation to evaluate a man’s or a woman’s fertility. Treatment usually lasts for at least three or four months. Be aware that herbal therapy is not recommended during ART cycles.

Various studies have claimed that TCM can be used to regulate the menstrual cycle, regulate hormones by reducing stress, improve blood flow to the ovaries and uterus, improve ovarian function to encourage production of follicles, improve the thickness of the uterine wall lining, reduce uterine contractions after embryo transfer, reduce the chance of miscarriage, and improve sperm parameters and the quality of eggs.

Researchers from Yale University and Chang Gung Institute of Technology in Taiwan reviewed recent studies of TCM in fertility. They found that TCM could regulate gonadotropin-releasing hormone (GnRH) to induce ovulation and improve blood flow to the uterus and improve the menstrual changes of the endometrium. In addition, TCM had an impact on infertility patients with polycystic ovary syndrome, anxiety, stress, and immunological disorders.

However, these were mainly small, uncontrolled studies. The effective dose, side effects, and potential toxicity of TCM in the context of infertility treatment need to be studied in prospective, randomized control trials to demonstrate the safety and effectiveness of TCM treatments.

Acupuncture

Acupuncture involves the insertion of very fine needles into specific points on the body along the meridians to balance the flow of qi.

After reviewing your medical situation and taking a history, an acupuncturist takes your pulse and does an exam to determine your energy state. Then he or she will insert thin, sterile, disposable acupuncture needles into the skin along the meridians at specific positions according to your diagnosis. You lie still for about thirty minutes with the needles in place, as the acupuncturist stimulates the needles manually or with low-voltage electric current or infrared heat. In general, acupuncture treatments for fertility are recommended in courses of once or twice a week for at least three or four months.

Acupuncture is considered a safe procedure, but an inexperienced acupuncturist can potentially cause infection, bleeding, bruising, pain, or even organ puncture when placing the needles. The American Pregnancy Association warns that acupuncture needles inserted into the wrong meridian

point may lead to a miscarriage, so you should avoid acupuncture if you are pregnant. The cost of acupuncture ranges from a few hundred to a few thousand dollars, depending on how long you are treated and who is doing the treatment. Many insurance companies cover the cost of acupuncture treatments, but usually not to treat infertility. Check your insurance policy carefully.

As a fertility treatment, acupuncture is said to increase blood flow to the uterus, relax the cervix, and help stabilize the nervous system to allow the body to handle stress better. The effects of acupuncture may also be based on brain chemistry. Acupuncture may help to improve a woman’s chances of conceiving by balancing the hormones released by the brain. In 2002, Weill Cornell researchers examined the medical literature and found a clear link between acupuncture treatments and increased production of endorphins, the body’s natural painkilling brain chemicals. The studies they reviewed suggested that certain effects of acupuncture are mediated through endorphins, which influence gonadotropin secretion through their action on GnRH and the menstrual cycle. So it’s logical to hypothesize that acupuncture may influence ovulation and fertility.

They also found evidence that acupuncture increased blood flow to the uterus and improved the thickness of the uterine lining, which may allow it to be more receptive to implantation. This suggests that acupuncture may provide an excellent alternative for stress reduction in women undergoing infertility treatment.

The Pros and Cons of Acupuncture IVF Studies

The Weill Cornell researchers also noted one prospective, randomized controlled study by researchers at the University of Ulm in Germany that compared the pregnancy rates among 160 women undergoing IVF. Half of the women had acupuncture treatments for twenty-five minutes before and after embryo transfer, and the other half did not. After controlling for confounding variables, the acupuncture group had a significantly higher pregnancy rate (43 percent) than the control group (26 percent).

A more recent review in 2008 led by University of Maryland researchers found that acupuncture might improve the odds of conceiving if done immediately before or after embryo transfer. The analysis pooled results from seven studies on 1,366 women in the United States, Germany, Australia, and Denmark. The women were randomly assigned to receive IVF alone, IVF with acupuncture within a day of embryo transfer, or IVF plus sham acupuncture, in which needles were placed too shallowly or in spots without meridians. One of the studies found acupuncture was beneficial, three studies found a trend in favor of acupuncture, and one study found acupuncture had no benefit. The researchers pooled the results of the smaller studies and found adding acupuncture improved the odds of conception by 65 percent.

But this type of pooled analysis is not proof that acupuncture helps. Since IVF pregnancy rates are at about 50 percent, adding acupuncture might boost a woman’s chance of having a baby by about 10 percent. Also, results from these studies should be interpreted with caution. Pregnancy rates without acupuncture varied widely in the different trials and often depended on which country the IVF clinic was in. In clinics where pregnancy rates after IVF were higher, the benefit of acupuncture was smaller. Although this review shows acupuncture has promise, more studies are needed to confirm whether acupuncture can be recommended as an adjunctive treatment alongside IVF.

In contrast, a review in 2009 by researchers at Guy’s and St. Thomas’ Hospitals in London found that acupuncture may not improve IVF success rates. The researchers analyzed data from fourteen randomized clinical trials involving 2,870 women. Five trials included 877 women who had IVF with or without acupuncture treatments during egg retrieval. Those studies showed no significant difference in the pregnancy rate between those who had acupuncture and those who acted as controls. The other nine trials included 1,993 women who had IVF with or without acupuncture performed at the time of embryo transfer. These studies also reported no substantial difference in pregnancy rates.

Another randomized, prospective study in 2009 by researchers at Boston IVF examined the impact of acupuncture and IVF outcomes. The researchers randomly assigned 150 women about to undergo IVF to have acupuncture or no acupuncture before and after embryo transfer. The women also filled out questionnaires on their anxiety levels and how optimistic they were about the success of the IVF cycle. The acupuncture did not lead to higher pregnancy rates, but those who had acupuncture reported that they were less anxious after the embryo transfer and more optimistic about the outcome of their IVF cycle.

A 2008 Cochrane Collaboration review of data from thirteen studies found no strong evidence that acupuncture improves pregnancy rates, although one study did show a slight increase in the live-birth rate among women who underwent acupuncture on the day of embryo transfer. A number of other recent studies have addressed the use of acupuncture in patients undergoing treatment for infertility. Some show benefit, while others do not.

With all of this conflicting research on acupuncture in IVF, it’s hard to know its true effect in improving your chances of taking home a baby. More well-conducted clinical trials are needed to substantiate the use of acupuncture in improving IVF pregnancy rates.

The gold standard of medical testing is the randomized, double-blind clinical trial, in which neither the patients nor the doctors know which treatment is being given. But it may be difficult to do a convincing double-blind trial in a treatment as invasive as acupuncture. The participants have to believe they are being stuck with actual needles. “Placebo” acupuncture with needles that retract into the handle when pressed against the body and don’t penetrate the skin might be too realistic and could induce the placebo effect, which means that if you believe that something will work, it really does work. Or the pressure of the placebo acupuncture might induce a response similar to real acupuncture.

That’s what researchers at the University of Hong Kong in China found when they looked at real and placebo acupuncture given on the day of embryo transfer in 370 patients in a randomized, double-blind trial. A trained acupuncturist applied the placebo acupuncture to the same acupuncture points as in the real acupuncture. Surprisingly, the researchers found that the overall pregnancy rate for the placebo acupuncture was significantly higher (55 percent) than for the real acupuncture (44 percent).

They speculate that the placebo acupuncture acted like acupressure, a form of acupuncture that uses manual pressure on the meridian points instead of needles pushed into the points. Blood tests showed that women in both groups had a decrease in the stress hormone cortisol and lower levels of anxiety. That may have increased their chances of conception. The researchers admit they cannot draw firm conclusions about the study because they did not compare the two groups with a third, control group of patients who did not receive either form of acupuncture.

The bottom line is that the jury is still out as to whether acupuncture can help increase your chances of getting pregnant with IVF. There are still some unresolved issues, but it’s unlikely that acupuncture does any harm, and it probably does reduce the stress associated with fertility treatment. If you do decide to try acupuncture, always check on the training and qualifications of the acupuncturist. The National Certification Commission for Acupuncture and Oriental Medicine (http://www.nccaom.org/find/ index.html) can help you locate a board-certified, licensed acupuncturist in your area.

Chinese Herbs

Many Chinese herbal therapies are said to improve the chances of conception. The herbs address underlying imbalances so that the body can function more healthfully. In the treatment of infertility, herbs are used to promote hormone balance, improve sperm and egg quality, regulate the menstrual cycle, enhance mucus secretions, tone the uterus, nourish the endometrial lining, and maintain pregnancy.

TCM herbal therapy generally uses combinations of herbs. Each herbal prescription is uniquely tailored to a patient’s detailed health history. The formula is carefully balanced to accentuate the patient’s strengths and to reduce the possibility of side effects. The different herbs combined in a formula can be made into teas (decoctions), powders, or pills.

Chinese herbs offered to women for the treatment of infertility include damiana, dong quai, chaste tree, ginseng, and hachimijiogan. Chinese herbs used to treat male infertility include deer antler, rehmannia, gui-zhi-fu-lingwan, bushen shengjing pill, ju jing powder, hachimijiogan, and ninjinotoh.

TCM herbalists have extensive training and clinical experience and do not encourage self-medication, which may be harmful or even fatal. They claim to be able to treat infertility effectively and believe that herbs cause fewer side effects than fertility drugs, but they usually are willing to work in conjunction with conventional medical treatments.

The mechanisms of how Chinese herbal therapy works is not well understood. One possibility is the herbs act as antioxidants as well as antiestrogens. Researchers at the University of Kent in England studied the biochemical activity of Chinese herbs commonly used in the treatment of male infertility, including thirty-seven individual herbs and seven herb decoctions. They found a range of strong to weak antioxidant and antiestrogen effects. Since the process of sperm formation is under strict hormonal control, and oxidative stress, which causes the formation of free radicals, has been implicated in male infertility, this is a plausible mechanism of action for Chinese herbs.

ABOUT THE AUTHORS
Zev Rosenwaks, MD, author of A Baby at Last!: The Couple’s Complete Guide to Getting Pregnant — from Cutting-Edge Treatments to Commonsense Wisdom (Copyright © 2010 by Zev Rosenwaks, MD, Marc Goldstein, MD, and Mark L. Fuerst), is the Director of The Center for Reproductive Medicine and Infertility, the world-renowned infertility clinic at New York Weill Cornell. He is a world known authority on reproductive endocrinology and infertility and one of the founding pioneers in the assisted reproductive technologies. He was part of the medical team that successfully used IVF for the first time in the U.S. in 1981. Dr. Rosenwaks is Professor of Obstetrics and Gynecology at Weill Medical College of Cornell University and was appointed an endowed professorship in 1994 — the Revlon Distinguished Professor of Reproductive Medicine in Obstetrics and Gynecology. He is a diplomat of the American Board of Obstetrics and Gynecology and received his subspecialty certification in Reproductive Endocrinology in 1981.

Marc Goldstein, MD
, author of A Baby at Last!: The Couple’s Complete Guide to Getting Pregnant — from Cutting-Edge Treatments to Commonsense Wisdom (Copyright © 2010 by Zev Rosenwaks, MD, Marc Goldstein, MD, and Mark L. Fuerst), is Professor of Reproductive Medicine and Professor of Urology at Weill Medical College of Cornell University, Surgeon-in-Chief, Male Reproductive Medicine and Surgery, Executive Director, Men’s Service Center of the Cornell Institute for Reproductive Medicine and Director of the Center for Male Reproductive Medicine and Microsurgery at the New York Weill Cornell University Medical Center. He is Senior Scientist with the Population Council’s Center for Biomedical Research, located on the campus of Rockefeller University. He recently became the Matthew P. Hardy Distinguished Professor of Reproductive Medicine and Urology at Weill Cornell and in Spring 2008 was named Doctor of Science (Honorary) at the State University of New York Downstate Medical Center.

Mark L. Fuerst, author of A Baby at Last!: The Couple’s Complete Guide to Getting Pregnant — from Cutting-Edge Treatments to Commonsense Wisdom (Copyright © 2010 by Zev Rosenwaks, MD, Marc Goldstein, MD, and Mark L. Fuerst), is a health and medical writer and the co-author of nine books, including the three editions of The Couple’s Guide to Fertility As a free-lance journalist for more than 30 years, his articles have appeared in popular consumer magazines such as Family Circle, Woman’s Day, Health, Parents, and Self. His articles on fertility have appeared in Good Housekeeping, Woman’s World, Baby Talk, and the United Features newspaper syndicate. Fuerst earned a biology degree from Dickinson College and a master’s degree in journalism from the University of Missouri at Columbia. He lives in Brooklyn, NY, with his wife and two children.

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