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European Journal of Integrative Medicine xxx (2014) xxx.e1–xxx.e5

Original article

A case series of acupuncture treatment for female infertility with some cases
supplemented with Chinese medicines
Shiu Hon Chui a,∗ , Fung Chun Chow b , Yim Tong Szeto c , Kelvin Chan d,e , Christopher W.K. Lam a
a Macau Institute for Applied Research in Medicine and Health, Macau University of Science and Technology, Macau
b Modern TCM Ltd., Hong Kong Special Administrative Region
c Department of Applied Science, Hong Kong Institute of Vocational Education (Shatin), Hong Kong Special Administrative Region
d Centre for Complementary Medicine Research, University of Western Sydney, Sydney, NSW 2751, Australia
e Faculty of Pharmacy, The University of Sydney, Sydney, NSW 2006, Australia

Received 10 August 2013; received in revised form 26 February 2014; accepted 5 March 2014

Abstract
Introduction: Delayed marriage is a prominent trend among Chinese citizens in Hong Kong. Such substantial delays expectedly postpone the
age of pregnancy, to the extent that aging has become a risk factor for female infertility. There are many underlying reasons for female infertility.
Acupuncture has been used in traditional Chinese medicine (TCM) and is suggested to be effective for treating infertility. The objective of this
study was to observe the outcome of acupuncture treatment on infertile females with some cases supplemented with CM.
Materials and methods: In this case series, female patients who sought medical consultations for infertility were clinically observed. They were
treated either with acupuncture alone or with prescriptions of Chinese medicines (CM), based on individual’s condition and/or pathogenesis of the
disease. There was no obvious major cause of infertility in terms of Western medical diagnosis, yet 15 patients were classified as having “Stagnation
of Liver qi” according to Chinese medicine diagnosis theory. Twenty-one patients who completed the course of treatment were studied. Eight
patients were treated with acupuncture only, while the remaining 13 patients received acupuncture treatment supplemented with CM.
Results: Over a period of two years there were 14 women who were successful in becoming pregnant (66.7%) and 7 patients were not yet pregnant
upon termination of treatment. None of the 21 cases exhibited any adverse effects.
Conclusion: These observations suggest that acupuncture, either with or without CM supplementation, could be an effective option for treating
infertility.
© 2014 Elsevier GmbH. All rights reserved.

Keywords: Acupuncture; Female infertility; Conception; Ovulation; Chinese medicine

Introduction Kong over the last decade [1], there are still a significant number
of couples who marry at an older age and who seek assistance
Delayed marriage is a prominent trend among Chinese citi- for conception.
zens in Hong Kong. Mean ages at marriage were 29.7 and 27.1 Female infertility is defined as no conception within 1
years respectively for men and women in 1986, with correspond- year with unprotected intercourse during the fertile phase of
ing increases to 33.3 and 30.8 years in 2006 [1]. Such substantial menstrual cycles [3]. Secondary infertility is similar but the
delays expectedly postpone the age of pregnancy, to the extent patient has previously given birth at least once. There are many
that aging has become a risk factor for female infertility [2]. underlying reasons for female infertility. Treatments include
Although there has been a downward trend on birth rate in Hong medications and sometimes employing hormones for induc-
tion of ovulation. Surgical techniques are commonly used
too. However, most of the treatment strategies incur signifi-
∗ Corresponding author at: 612 Melbourne Plaza, 33 Queen’s Road Central, cant discomfort, side-effects and are sometimes invasive [4].
Hong Kong Special Administrative Region. Tel.: +852 2116 0788. Acupuncture has been used in traditional Chinese medicine
E-mail address: [email protected] (S.H. Chui). (TCM) and is suggested to be effective for treating infertility
http://dx.doi.org/10.1016/j.eujim.2014.03.007
1876-3820/© 2014 Elsevier GmbH. All rights reserved.

Please cite this article in press as: Chui SH, et al. A case series of acupuncture treatment for female infertility with some cases supplemented
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[5]. Acupuncture may mediate the release of neurotransmitters, 6. major illnesses which in the opinion of the investigators
which may in turn stimulate secretion of gonadotrophin releas- would make the subject unsuitable for the study or unable
ing hormone, thereby influencing the menstrual cycle, ovulation to comply with the treatment schedule.
and fertility [6]. It may stimulate blood flow to the uterus by
inhibiting uterine central sympathetic nerve activity [6]. Also, A successful case was defined as a patient achieving preg-
acupuncture may stimulate the production of endogenous opi- nancy within 2 years after the commencement of treatment.
oids, which may inhibit the central nervous system outflow and Those who did not complete the 2-year treatment period and/or
the biological stress response [6]. A recent review concluded that did not conceive were classified as ‘non-pregnant’ instead of
acupuncture can improve the outcome of IVF and the mech- being unsuccessful.
anisms may be related to the increased levels of depression, The demographic details of the recruited subjects are sum-
anxiety and stress [5,7]. This was a case series and the aim marized in Table 1.
of the present study was to observe the outcome of acupunc-
ture on infertile females in the local context with some cases Treatment
supplemented with TCM prescription medicines. Nevertheless,
acupuncture was the main treatment and use of CM was only Basic anatomical and physiological knowledge on female
an adjunct therapy that was used as appropriate for helping the genital structure and reproduction was explained to patients
acupuncture. during the first consultation. The details of treatment strategy
and prognosis were also discussed and shared with patients for
enhancing compliance.
Materials and methods Patients were requested to start acupuncture treatment for
two to three times a week after menstruation. Acupuncture on
Subjects 3 consecutive days was performed during the ovulation period,
mainly days 12, 13 and 14, and two to three times a week dur-
This study took place from October 2004 to June 2009. It ing the luteal phase. Patients were advised to have intercourse
was approved by the Clinical Research Ethics Committee of the once every 2 days, starting several days before and after the
Macau University of Science and Technology, Macau (MUST), ovulation period to promote the chance of pregnancy. Each
and conducted at the clinics of Modern TCM Ltd. (MTCM) in acupuncture treatment lasted 25 min. Sterile disposable stain-
Hong Kong, which is an affiliation of MUST in Hong Kong. less steel needles (0.22 × 25 mm) were inserted in acupuncture
Female patients with infertility problem visiting MTCM were point locations. Needles were stimulated to elicit the sensation
observed and followed up for the study as part of their nor- of de qi twice and were left in position for 25 min and then
mal treatment with informed written consent. The diagnosis of removed. The depth of needle insertion was about 10 to 20 mm,
infertility was made according to the People’s Republic of China depending on the region of the body undergoing treatment. The
Chinese Medical Practice Standard [8]. main acupuncture points used were EX-CA1 (Zigong), EX-CA2
Patients who fulfilled the following criteria were included: (Sanjiaojiu), CV3 (Zhongji), CV4 (Guanyuan), CV6 (Qihai),
SP6 (Sanyinjiao), and the coordinating acupuncture points were
1. normal child bearing age, i.e. >21 to <45 years of age; CV12 (Zhongwan), SP10 (Xuehai), ST36 (Zusanli) and LR3
2. married for longer than one year and having no concep- (Taichong) (Fig. 1). These acupuncture points were selected
tion with unprotected intercourse during the fertile phase of according to the principles of TCM [9,10] and the protocols
menstrual cycle; were designed based on the accumulated clinical experience of
3. non-smoking and non-drinkers; the acupuncturist over 10 years. Stimulation of Taiyin meridi-
4. willing to receive treatment with acupuncture and Chinese ans (Spleen) and Yangming meridians (Stomach, Colon) would
medicines; result in better blood perfusion and more energy in the uterus.
5. whose husband had healthy sperm and was able to engage in Stimulation of the body points CV3, CV4, CV6 and CV12
sexual activity. would nourish the blood and supplement the essence. LR3 would
sedate the patient. Acupuncture points contradictory to preg-
Patients having the following conditions were excluded: nancy, lower abdominal points, and the SP6 were avoided during
the luteal phase.
Chinese prescription medicines were prescribed to some
1. major problems associated with cardiac, respiratory, renal of the patients according to the pathogenesis of respective
and hepatic functions; problems. For example, Chaihu Shugan San (consisting of
2. HIV subjects (by history only; laboratory confirmation not Radix Bupleuri, Radix Paeoniae Alba, Fructus Aurantii, Peri-
required); carpium Citri Reticulatae, Rhizoma Cyperi, Rhizoma Ligustici
3. I.V. or other prohibited substance users; Chuanxiong and Radix Glycyrrhizae) was prescribed for
4. use of any traditional Chinese medicine therapy for infertility Stagnation of Liver qi to sooth the liver, regulate the circulation
at least one month prior to entering the study; of qi and monitor menstruation to relieve pain, and Taohong
5. use of any other investigational drug(s) 1 month prior to Siwu Tang (consisting of Radix Rehmanniae Praeparata,
entering the study; Radix Paeoniae Alba, Radix Angelicae Sinensis, Rhizoma

Please cite this article in press as: Chui SH, et al. A case series of acupuncture treatment for female infertility with some cases supplemented
with Chinese medicines. Eur J Integr Med (2014), http://dx.doi.org/10.1016/j.eujim.2014.03.007
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Table 1
Patient demographic details.
Patients Age Years of marriage Years of infertility BMI Patients Age Years of marriage Years of infertility BMI

1 33 6 2 19.40 12 35 2 2 21.91
2 33 5 2 19.88 13 39 2 2 22.10
3 35 10 2 20.31 14 37 10 3 22.48
4 35 2 2 20.66 15 33 5 5 22.89
5 31 4 3 20.70 16 37 5 5 22.89
6 35 6 4 21.08 17 38 10 7 23.05
7 37 8 8 21.50 18 37 7 7 23.73
8 39 6 2 21.50 19 39 8 8 24.22
9 35 2 2 21.50 20 35 9 9 24.61
10 35 5 2 21.64 21 35 10 10 25.54
11 33 5 2 21.72

Ligustici Chuanxiong, Semen Persicae and Flos Carthami) was

prescribed for stasis in uterus to invigorate blood circulation,
normalize menstruation and eliminate blood stasis to relieve
pain. The ultimate purpose was to alleviate pathological causes
of infertility so that acupuncture could enhance conception.
The rationale and possible benefits with the use of CM in
support of acupuncture were explained to all patients of the
study. However, some patients declined to take CM mainly due
to personal preference. It therefore resulted in that only two
groups of patients (Stagnation of Liver qi and Stasis in uterus)
were treated with CM instead of all the four groups.
A flowchart summarizing the whole process of the trial and
outcomes is shown in Fig. 2.

Results

A total of 21 patients were recruited and completed the 24-

month treatment period. Patients’ ages ranged from 31 to 39
years, with an overall mean of 35.5 years and median of 35 years.
Table 1 shows the age and body mass index (BMI) of individual
patient at the entry of the study. The period of infertility for these
patients ranged from 2 to 10 years (mean = 4.2 years). Eighteen
of the 21 patients (85.7%) were diagnosed as having primary
infertility, while three (14.3%) were defined as having secondary
infertile. The relevant information of infertility including dura-
Fig. 1. The schematic diagram of acupoints of EX-CA1, EX-CA2, CV3, CV4, tion, types and causes, as well as the number of successful cases
CV6 CV12, SP6, SP10, ST36 and LR3. (EX-CA1: 3 cun lateral to CV3. EX- are summarized in Table 2. No complaints of adverse effects
CA2: Use the distance between the two corners of the mouth of the patient as were received from patients. Among the 21 patients, 14 became
the length of one side of an equilateral triangle. Place the apex of this equilat- pregnant and 7 remained non-pregnant. Among the 14 success-
eral triangle at the center of the umbilicus and the base line is horizontal. The
points are located at the two bottom angles of the triangle. CV3: 4 cun below
ful cases, 11 of them achieved pregnancy naturally, 2 with IVF
the umbilicus. CV4: 3 cun below the umbilicus. CV6: 1.5 cun below the umbili- and 1 with IUI.
cus. CV12: the midpoint between umbilicus and sternocostal angle. SP6: 3 cun Results indicated that out of the 14 successful cases,
directly above the tip of medial malleolus, on the posterior border of the tibia. the majority (10 cases) were conceived within 12 months
SP10: When the knee is flexed, the point is on the medial side of the thigh, 2 of acupuncture treatment (10/14 patients, 71.4%), and most
cun above medial border of the patella, on the bulge of the medial portion of
m.quadriceps femoris. ST36: 3 cun below ST35 (Dubi) and 1 cun lateral to the
received fewer than 40 sessions of acupuncture treatment. These
anterior crest of the tibia. LR3: In the depression distal to the junction of the 1st observations suggested that acupuncture could be useful for
and 2nd metatarsal bones.) treatment of female infertility over a relatively short period of
time (Table 3).
Nevertheless, it is noted that some patients might need a
much longer treatment period to achieve the effect. In the study
group, there was no obvious major infertility cause according to

Please cite this article in press as: Chui SH, et al. A case series of acupuncture treatment for female infertility with some cases supplemented
with Chinese medicines. Eur J Integr Med (2014), http://dx.doi.org/10.1016/j.eujim.2014.03.007
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Table 2
Relevant information of infertility including duration, types and causes.
Years of infertility (primary/secondary/S) Causes of female infertility

According to Western medicine (T/S) According to Chinese medicine (T/S)

2–4 (11/2/7) General factorsa (11/7) Kidney yin deficiency (2/0)

Uterine myoma (4/3) Stagnation of Liver qi (15/11)
5–7 (4/0/4) Uterus retroversion (1/1)
Polycystic ovary syndrome (1/1) Internal obstruction of Phlegm-Dampness
8–10 (3/1/3) Ovulation dysfunction (1/1) (1/1)
Premature ovarian failure (3/1) Stasis in uterus (3/2)
Total (18/3/14) Total (21/14) Total (21/14)

T = total numbers; S = successful conception.

a Including advanced age, over-weight, malnutrition, exhaustion, anxiety, drug-abuse, etc.

Western medical diagnosis (Table 2), but 15 patients were clas-

First medical consultation for
infertility problem sified as ‘Stagnation of Liver qi’ using TCM diagnosis (Table 2).

Discussion
Diagnosis of infertility
Female infertility is a common gynecological problem with
multiple pathogenesis. It may originate from dysfunction of
Explaining the basic anatomical & physiological the uterus, oviduct or ovulation. It is estimated that the infer-
knowledge on female genital structure and tility rate is about 15% among women at the child-bearing
reproduction as well as details of treatment
strategy and prognosis to patients
age [11]. It has been suggested that acupuncture moderates
the hypothalamic-pituitary-ovarian axis and hence modulates
the menstrual cycle. The ␤-endorphin induced by acupunc-
Informed consent received
ture influences the release of gonadotropin-releasing hormone
(N=21) (GnRH), which in turn affects the secretion of gonadotropin
[12]. It has also been reported that auricular acupuncture offers
similar efficacy as hormonal therapy on female patients with
endocrinologic infertility [13]. The hormonal imbalance can be
Commencement of treatment
related to the ‘syndrome of deficiency’ according to TCM diag-
nosis and treatment principles. Acupuncture is also effective
in improving cardiovascular circulation which can solve prob-
lems of ‘Blood-Stasis’ and ‘qi-Stagnation’. Through improving
Acupuncture treatment only Acupuncture + Chinese
(N=8) medicine treatment (N=13) circulation of the uterus and ovary, acupuncture is useful in
treating infertility with no adverse effects [14]. Our results
were able to show the positive effect on treatment of infertility
Pregnancy in Pregnancy in 1 to
in 11 out of 15 patients who were diagnosed with Stagna-
<1 to 18 months (N=6) 20 months (N=8) tion of Liver qi (11 successful cases out of 15 as shown in
Table 2).
Fig. 2. Process flowchart. In vitro fertilization (IVF) is a common option for infer-
tility patients. It requires sophisticated technology and the
cost is unavoidably high. Besides, the risks and chance of

Table 3
Period of acupuncture treatment (with and without Chinese medicine) and number of successful cases.
Treatment period in months (sessions) Number of successful conception

Acupuncture only Acupuncture plus Chinese medicines

<1 (4) 1 0
1–6 (9–36) 4 3
7–12 (36–41) 0 2
13–18 (63) 1 0
19–20 (64–95) 0 3
Total 6 8

Please cite this article in press as: Chui SH, et al. A case series of acupuncture treatment for female infertility with some cases supplemented
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Please cite this article in press as: Chui SH, et al. A case series of acupuncture treatment for female infertility with some cases supplemented
with Chinese medicines. Eur J Integr Med (2014), http://dx.doi.org/10.1016/j.eujim.2014.03.007