Acupuncture, a form of alternative medicine is the stimulation of specific acupuncture points along the skin of the body using thin needles. It is commonly used for pain relief, though it is also used to treat a wide range of conditions. Acupuncture is rarely used alone but rather as an adjunct to other treatment modalities. In Western settings acupuncture is used as a primary intervention for fertility problems. Acupuncture is increasingly used as an adjunct to assisted reproductive technologies and more widely in the complementary health care system.
The Western medical acupuncture approach involves using acupuncture after a medical diagnosis. In traditional acupuncture, the acupuncturist decides which points to treat by observing and questioning the patient to make a diagnosis according to the tradition used.
This method has always been applied to reproductive treatment in China. Western medicine may exert influence on neuroendocrine system, immunological functions and even signal pathway in consideration when discussing the efficacy of acupuncture and these still continue to be studied. The Chinese medicine evaluates the effect of acupuncture from an overall perspective. In Chinese medicine, reproductive function relates not only to reproductive organs, but also to the kidney, the liver, and the heart.
Acupuncture can be used as an adjuvant treatment for unexplained infertility. Although acupuncture did not increase the cumulative pregnancy rate, it decreased the number of control ovarian hyperstimulation (COH) cycles and more patients got pregnant in natural cycles after receiving acupuncture (Tab. 1).
Acupuncture treatment procedures should happen once or twice a week, and will continue for anywhere from a few weeks to a few months. Remember the process may take more time than just twice a week if you are combining it with medical infertility treatments, like IVF. In general, the acupuncture treatment can be completed in 12 appointments. At each appointment, your acupuncturist will most likely take additional time to discuss your current condition and answer any questions that you may have.
Traditional Chinese medicine (TCM) is a style of traditional Asian medicine informed by modern medicine but built on a foundation of more than 2,500 years of Chinese medical practice that includes various forms of herbal medicine, acupuncture, massage (tui na), exercise (qigong), and dietary therapy. It is primarily used as a complementary alternative medicine approach. TCM is widely used in China and is becoming increasingly prevalent in Europe and North America.
One of the basic tenets of TCM "holds that the body's vital energy (chi or qi) circulates through channels, called meridians, that have branches connected to bodily organs and functions." Concepts of the body and of disease used in TCM reflect its ancient origins and its emphasis on dynamic processes over material structure, similar to European humoral theory. Scientific investigation has found nohistological or physiological evidence for traditional Chinese concepts such as qi, meridians, and acupuncture points. The TCM theory and practice are not based upon scientific knowledge, and its own practitioners disagree widely on what diagnosis and treatments should be used for any given patient. The effectiveness of Chinese herbal medicine remains poorly researched and documented. There are concerns over a number of potentially toxic plants, animal parts, and mineral Chinese medicinals. A review of cost-effectiveness research for TCM found that studies had low levels of evidence, but so far have not shown benefit outcomes. Pharmaceutical research has explored the potential for creating new drugs from traditional remedies, with few successful results. A Nature editorial described TCM as "fraught withpseudoscience", and said that the most obvious reason why it hasn't delivered many cures is that the majority of its treatments have no logical mechanism of action. Proponents propose that research has so far missed key features of the art of TCM, such as unknown interactions between various ingredients and complex interactive biological systems.
TCM's view of the body places little emphasis on anatomical structures, but is mainly concerned with the identification of functional entities (which regulate digestion, breathing, aging etc.). While health is perceived as harmonious interaction of these entities and the outside world, disease is interpreted as a disharmony in interaction. TCM diagnosis aims to trace symptoms to patterns of an underlying disharmony, by measuring the pulse, inspecting the tongue, skin, and eyes, and looking at the eating and sleeping habits of the person as well as many other things.
The fundamental principles of TCM are based on the Yin-Yang doctrine, the symbolic way of designating opposing forces, and the five element theory that everything in the Universe is dominated and balanced by the five elements, wood, fire, earth, metal and water. The therapeutic mechanism of TCM focuses on enhancing human body's resistance to diseases by improving the inter-connections among self-controlled systems and integrating the human body with the environment. The practice of TCM involves physical therapy such as acupuncture and chemical therapy using materials originating from plants, minerals and animals, while TCM natural products may comprise one or more herbs in the form of decoctions.
In Chinese philosophy, the concept of yin yang sometimes referred to in the west as yin and yang) is used to describe how polar or seemingly contrary forces are interconnected and interdependent in the natural world, and how they give rise to each other in turn. Many natural dualities — e.g. dark and light, female and male, low and high, cold and hot — are thought of as manifestations of yin and yang (respectively).
Yin yang are complementary opposites within a greater whole. Everything has both yin and yang aspects, although yin or yang elements may manifest more strongly in different objects or at different times. Yin yang constantly interacts, never existing in absolute stasis. The concept of yin and yang is often symbolized by various forms of the Taijitu symbol, for which it is probably best known in western cultures. There is a perception (especially in the West) that yin and yang correspond to good and evil. However, Taoist philosophy generally discounts good/bad distinctions as superficial labels, preferring to focus on the idea of balance.
In TCM, there are five diagnostic methods: inspection, auscultation, olfaction, inquiry, and palpation.
Inspection focuses on the face and particularly on the tongue, including analysis of the tongue size, shape, tension, color and coating, and the absence or presence of teeth marks around the edge.
Auscultation refers to listening for particular sounds (such as wheezing). Olfaction refers to attending to body odor. Inquiry focuses on the "seven inquiries", which involve asking the person about the regularity, severity, or other characteristics of: chills, fever, perspiration, appetite, thirst, taste, defecation, urination, pain, sleep, menses, leukorrhea. Palpation which includes feeling the body for tender A-shi points, and the palpation of the wrist pulses as well as various other pulses, and palpation of the abdomen. Examination of the tongue and the pulse are among the principal diagnostic methods in TCM.Certain sectors of the tongue's surface are believed to correspond to the zàng-fŭ. For example, teeth marks on one part of the tongue might indicate aproblem with the Heart, while teeth marks on another part of the tongue might indicate a problem with the Liver. Pulse palpation involves measuring the pulse both at a superficial and at a deep level at three different locations on the radial artery (Cun, Guan, Chi, located two fingerbreadths from the wrist crease, one fingerbreadth from the wrist crease, and right at the wrist crease, respectively, usually palpated with the index, middle and ring finger) of each, for a total of twelve pulses, all of which are thought to correspond with certain zàng-fŭ. The pulse is examined for several characteristics including rhythm, strength and volume, and described with qualities like "floating, slippery, bolstering-like, feeble, thready and quick"; each of these qualities indicate certain disease patterns. Learning TCM pulse diagnosis can take several years.
Chinese medicine therapies
Hysteroscopy (Pic. 1) is a procedure used to examine the inside of the womb (uterus).
The introduction of hysteroscopy in gynecologic practice revolutionized the diagnosis and treatment of intrauterine disease.
New methodological and technological developments have made diagnostic and operative hysteroscopy much more efficient, cost effective, safe, and useful. The most common indication for hysteroscopy is abnormal uterine bleeding (AUB), but it is also used in cases of infertility and Mullerian anomalies.
Uterine factors can be found in only 2 to 3% of infertile women, but intrauterine lesions are much more common in this setting (40–50%). These lesions can compromise spontaneous fertility as well as reduce pregnancy rates in assisted reproduction.
Published observational studies suggest increased pregnancy rates after the hysteroscopic removal of endometrial polyps, submucous fibroids (Pic. 2), uterine septum, or intrauterine adhesions (Pic. 3), which can be found in 10% to 15% of women seeking treatment for subfertility.
The assumption of the minimal invasiveness of hysteroscopy is based on facts such as the miniaturisation of scopes, the uncommon need of anaesthesia and the progressive simplification of the technique. Based on fine hysteroscopes (Pic. 4, 5; a telescope attached to a light source, which then is passed into the uterine cavity) produced recently, hysteroscopy can be easily performed in an office-based environment. The more attractive office environment compared with the conventional operating theater, the no-need for general anaesthesia and the reduced cost compared to the classic hysteroscopy are the main advantages that characterize office hysteroscopy and that made it more popular during the last years.
The diameter of the hysteroscope is generally too large to conveniently pass the cervix directly, thereby necessitating cervical dilation to be performed prior to insertion. Cervical dilation can be performed by temporarily stretching the cervix with a series of dilators of increasing diameter. The hysteroscope with its sheath is then inserted transvaginally guided into the uterine cavity, the cavity insufflated, and an inspection is performed. The uterine cavity is a potential cavity and needs to be distended to allow for inspection. Current recommendation is to use the electrolytic fluids in diagnostic cases, and in operative cases in which mechanical, laser, or bipolar energy is used. Each of distention fluids is associated with unique physiological changes that should be considered when selecting a distention fluid.
The technique does not have absolute contraindications but, in general, it is not indicated in acute inflammatory pelvic disease, cervicitis (an inflammation of cervix), after recent uterine perforation and if pregnancy is suspected or confirmed, when risks and benefits should be considered.
Microsurgery of blocked tubes is a treatment option for women whose tubes were blocked by tubal ligation (Pic. 1) and with this procedure they can be rejoined again.
Microsurgical tubal reanastomosis (a reconnection between two things) can be used to restore fertility by rejoining the separated segments of the Fallopian tube which was blocked by tubal ligation (a surgical procedure for sterilization in which a woman's fallopian tubes are clamped and blocked).
In this process, the area of the tubes which was occluded is removed, leaving only open, healthy tube. These open, healthy, tubal segments are then connected. A multi layer, micro surgical technique is used to suture these segments together.
After the tubes are repaired, a chromopertubation (a procedure usually done during a laparoscopy to visualize the fallopian tubes in order to see if they are patent or open) is performed wherein dye is injected into the uterus. This dye is passed through the repaired tubes to ensure that the tubes are open.
The entire surgery is performed through a small incision of about 3 to 4 inches just at the uppermost part of the hair line.
During ICSI just one sperm is injected directly into the egg cytoplasm using a micromanipulative apparatus that transforms imperfect hand movements into fine and precise movements of micromanipulation tools.
Intracytoplasmic Sperm Injection (ICSI) is an assisted reproductive technique (ART) initially developed by Dr. Gianpiero D. Palermo in 1993 to treat male infertility. It is most commonly used in conjunction with in vitro fertilization (IVF). Following IVF procedure, the physician places the fertilized egg into the female’s uterus for implantation. Sperm are obtained by the same methods as with IVF: either through masturbation, by using a collection condom, or by surgically removing sperm from a testicle through a small incision (MESA, TESE). The females are treated with fertility medications for approximately two weeks prior to oocyte retrieval to stimulate superovulation, where the ovaries produce multiple oocytes rather than the normal one oocyte. The oocytes are retrieved by either laparoscopy, or more commonly, transvaginal oocyte retrieval. In the latter procedure, the physician inserts a thin needle through the cervix, guided by a sonogram and pierces the vaginal wall and then the ovaries to extract several mature ova. Before the embryologist can inject the sperm into the oocyte, the sperm must be prepared by washing and exposing it to various chemicals to slow the sperm movement and prevent it from sticking to the injection plate. Also, the oocytes are treated with hyaluronidase to single out the oocyte ready for fertilization by the presence of the first polar body. Then, one prepared sperm is injected into an oocyte with a thin needle. Often, embryologists try to fertilize several eggs so they can implant more than one into the uterus and increase the chance of at least one successful pregnancy. This also allows them to save extra embryos, using cryopreservation, in case later IVF rounds are needed.
After the embryologist manually fertilizes the oocytes, they are incubated for sixteen to eighteen hours and develop into a pronucleate eggs (successfully fertilized eggs about to divide into an embryo). The egg then grows for one to five days in the laboratory before the physician places it in the female’s uterus for implantation.
The chance of fertilization increases dramatically with ICSI compared to simply mixing the oocytes and sperm in a Petri dish and waiting for fertilization to occur unaided (classical IVF procedure). Studies have shown that successful fertilizations occur 50% to 80% of the time. Since the introduction of ICSI, intrauterine insemination (IUI) has decreased in popularity by 80%.See full description of ICSI
In vitro fertilization (IVF) is a process by which an egg is fertilised by sperm outside the body: in vitro . The process involves monitoring and stimulating a woman's ovulatory process, removing an ovum or ova (egg or eggs) from the woman's ovaries and letting sperm fertilise them in a liquid in a laboratory. The fertilised egg (zygote) is cultured for 2–6 days in a growth medium and is then implanted in the same or another woman's uterus, with the intention of establishing a successful pregnancy.
IVF techniques can be used in different types of situations. It is a technique of assisted reproductive technology for treatment of infertility. IVF techniques are also employed in gestational surrogacy, in which case the fertilised egg is implanted into a surrogate's uterus, and the resulting child is genetically unrelated to the surrogate. In some situations, donated eggs or sperms may be used. Some countries ban or otherwise regulate the availability of IVF treatment, giving raise to fertility tourism. Restrictions on availability of IVF include to single females, to lesbians and to surrogacy arrangements. Due to the costs of the procedure, IVF is mostly attempted only after less expensive options have failed.
The first successful birth of a "test tube baby", Louise Brown, occurred in 1978. Louise Brown was born as a result of natural cycle IVF where no stimulation was made. Robert G. Edwards, the physiologist who developed the treatment, was awarded the Nobel Prize in Physiology or Medicine in 2010. With egg donation and IVF, women who are past their reproductive years or menopause can still become pregnant. Adriana Iliescu held the record as the oldest woman to give birth using IVF and donated egg, when she gave birth in 2004 at the age of 66, a record passed in 2006.
In the female reproductive system, the fimbria is a fringe of tissue around the ostium of the Fallopian tube, in the direction of the ovary.
An ovary is not directly connected to its adjacent Fallopian tube. When ovulation is about to occur, the sex hormones activate the fimbriae, causing it to swell with blood and hit the ovary in a gentle, sweeping motion. An oocyte is released from the ovary into the peritoneal cavity and the cilia of the fimbriae sweep the ovum into the Fallopian tube. This leads to tubal pregnancy. Hair-like cilia located on the internal surface of the Fallopian tubes carry the fertilized egg to the uterus. Fallopian cilia are sometimes seen in reduced numbers subsequent to an ectopic pregnancy, leading to a hypothesis that cilia damage in the Fallopian tubes is likely to lead to an ectopic pregnancy. As cilia degenerate the amount of time it takes for the fertilized egg to reach the uterus will increase. The fertilized egg, if it doesn't reach the uterus in time, will hatch from the non-adhesive zona pellucida and implant itself inside the fallopian tube, thus causing the pregnancy.
Female infertility caused by tubal phimosis can impede the descents of a fertilized or unfertilized ovum into the uterus through the Fallopian tubes and prevents a normal pregnancy and full term birth.
Tubal factor infertility represents around 20-25% of all the issues of infertility. The evaluation of the fallopian tube is necessary to determine the management plan of infertility. A number of diagnostic tests are being used in clinical practice to assess tubal patency as part of the work-up for subfertility.