Acupuncture for IVF and assisted reproduction : an integrated approach to treatment and management PDF
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Acupuncture for IVF and Assisted Reproduction TomyhusbandAlanandmychildrenDanielandMatthew.Mylifewouldnotbecompletewithoutyou! IrinaSzmelskyj TomysonOliverJacobAquilina-Ford. AlsointhelovingmemoryofmybabynephewGeorgioAquilina,andIndie. LianneAquilina ForElsevier ContentStrategists:ClaireWilson,AlisonTaylor ContentDevelopmentSpecialist:SallyDavies ProjectManager:SukanthiSukumar Designer:ChristianBilbow IllustrationManager:RichardTibbitts Illustrator:AntbitsLtd. Acupuncture for IVF and Assisted Reproduction An Integrated Approach to Treatment and Management Irina Szmelskyj DipAcMSc MBAcC LeadClinician,TrueHealthClinicsandFounderofTheFertilityFoundation,Godmanchester,Huntingdon; ModuleLeader,Lecturer and MSc Supervisor,Northern Collegeof Acupuncture, York; GuestLecturer, Universityof Lincoln, Lincoln, UK Lianne Aquilina DipAyuTAPA BSc(Hons)MBAcC ATCM Lead Clinician,Aquilia Acupuncture and Directorof Aquilia Fertility, Stamford, Lincolnshire; BSc(Hons) AcupunctureClinical Supervisor,Universityof Lincoln, Lincoln; SubjectSpecialist Guest Lecturer: TraditionalChineseMedicineinFertilityandIVF,UniversityofLincolnandVisitingGuestLecturer,Northern College ofAcupuncture,York, UK Edited by Alan O. Szmelskyj DO MSc AdvDipClinHyp FRSPH Senior Clinician,True Health Clinics, Godmanchester, Huntingdon; ScientificAdvisor, The Stress Management Foundation,Godmanchester, Huntingdon,UK Foreword by Giovanni Maciocia CAc (Nanjing) AcupuncturistandMedicalHerbalist VisitingProfessor,NanjingUniversityofTraditionalChineseMedicine,Nanjing,People’sRepublicofChina Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto 2015 TomyhusbandAlanandmychildrenDanielandMatthew.Mylifewouldnotbecompletewithoutyou! IrinaSzmelskyj TomysonOliverJacobAquilina-Ford. AlsointhelovingmemoryofmybabynephewGeorgioAquilina,andIndie. LianneAquilina ForElsevier ContentStrategists:ClaireWilson,AlisonTaylor ContentDevelopmentSpecialist:SallyDavies ProjectManager:SukanthiSukumar Designer:ChristianBilbow IllustrationManager:RichardTibbitts Illustrator:AntbitsLtd. ©2015ElsevierLtd.Allrightsreserved. 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The Publisher's policy is to use paper manufactured from sustainable forests PrintedinChina Biographies IRINA SZMELSKYJ IrinaSzmelskyjistheco-directorandleadclinicianofTrueHealthClinicsandisthefounderofThe FertilityFoundation. With more than a decade of experience specializing in reproductive healthcare, including the healthcareneedsofpatientswithinfertilityissuesandtheuseofacupunctureintheclinicalmanage- ment of patients undergoing assisted reproductive treatments such as In Vitro Fertilization (IVF), Irina’smethodofmanagingsubfertilepatientsisbasedonathoroughunderstandingofthevalue ofcombiningthebestofTraditionalChineseMedicine(TCM)andconventionalmedicine. Heruniqueapproachemphasizestheclinicalutilityofintegratingbothclassicallybasedtraditional acupuncturetreatmenttechniquesandconceptswiththepracticalclinicalapplicationofcontempo- raryevidence-basedadvances,fromtherapidlychanginglandscapeofreproductivemedicineresearch. Inadditiontoherclinicalexperience,IrinaholdsseveralacademicpostsattheNorthernCollegeof AcupunctureinYork,includingModuleLeaderfortheMScinAdvancedOrientalMedicineandMSc in Advanced Complementary Medicine courses, as well as supervising Masters level acupuncture students.Shealsolecturesundergraduateuniversitystudentsontheuseofacupuncturetreatment inthemanagementofinfertilityandduringIVF. In2006shewastherecipientoftheBritishAcupunctureCouncil’snationallyrecognizedAnnual Research Excellence Award. She is a member of the Acupuncture Fertility Network (AFN), the National Network of Zita West Affiliated Fertility Acupuncturists, the British Fertility Society, the AmericanSocietyforReproductiveMedicine(ASRM),andtheEuropeanSocietyofHumanReproduc- tionandEmbryology(ESHRE). LIANNE AQUILINA LianneAquilinaisfromafamilyofnursingspecialistsandstartedherearlycareerasaqualifieddental nursespecializinginanxietymanagementandreduction–askillthathasproveninvaluableinher fertilitywork.ShewentontostudycomplementarymedicinewiththespecializationofTraditional ChineseMedicalAcupuncture.In2005theFacultyofHealth,LifeandSocialSciencesoftheUniver- sityofLincolnawardedhertheDean’sprizeforStudiesinHealth.In2008Liannewasinvitedtojoin theUniversityofLincoln’steachingteamasanacupunctureclinicalsupervisor. LiannewaspartofthefirstgroupofTraditionalChinesemedicalpractitionersfromEnglandto completefurtherclinicaltrainingattheGuangdongProvinceSecondHospitalofTraditionalChinese Medicine(TCM)inChina.ItwasherethatsheobservedtheauthenticcombinationofTraditional Chineseandorthodoxmedicalstrategiesintreatmentandmanagement;shedevelopedtheseinsights forherpatientsundergoingInVitroFertilization(IVF)andothermethodsofAssistedReproductive Medicine(ART). ix Biographies Lianne’sinterestsledtofurtherstudyofChinesemedicalclassicsaspartofaMasterofArtspro- gramme, where she obtained a distinction from the College of Traditional Acupuncture, Warwick, UK,affiliatedwithOxfordBrookesUniversity(2009). Lianne Aquilina specializes in applied classical Chinese philosophy as the basis of Traditional ChineseMedicinereproductivehealth.Sheisanadvocateoftheimportanceofdevelopingthethera- peuticrelationshipandintegratingacupunctureintomainstreammedicineinresponsetothecon- temporaryhealthcareneedsofsubfertilepatients. Lianne’s research project as part of her degree was published in order to demonstrate various approachestoqualitativeresearchinhealthcare. ForseveralyearsLianneandIrinahaveteameduptolectureundergraduatestudentsontheuse of Traditional Chinese Medicine and acupuncture treatment and the management of subfertility andIVF. In2012,LiannewasaskedtojointheBritishAcupunctureAccreditationBoard(BAAB)asitsaccred- itationobserverfortheaccreditationofanMScacupuncturecourse.LianneisamemberoftheAsso- ciationofTraditionalChineseMedicine(ATCM)andtheBritishAcupunctureCouncil(MBAcC).She isanAssociateForumMemberofClassicalChineseMedicine,anAssociatememberoftheAyurvedic PractitionersAssociation(APA),theAmericanSocietyofReproductiveMedicine(ASRM),theBritish FertilitySociety(BFS)andanAcademicAssociateoftheBritishMedicalSociety(BMAS).Sheisthe Founder, Director and Lead Clinician of Aquilia Acupuncture and Aquilia Fertility in Stamford, Lincolnshire. ALAN SZMELSKYJ For several years Alan Szmelskyj was an editorial board member of the British Osteopathic Journal beforebecomingchiefeditorofthepeer-reviewedJournalofOsteopathicEducationandClinicalPractice. Alanhashadarticlesandcontributionspublishedinseveralpeer-reviewedmedicineandhealth- carejournalsincludingComplementaryMedicalResearch,ComplementaryTherapiesinMedicine,Holistic Medicine,ThePractitioner,ImagingandtheBMJamongstothers. PreviousappointmentsincludepreventativemedicinerolesintheOccupationalHealthDepart- mentsofbothHinchingbrookeNHSTrustandPapworthNHSTrust.AswellasaSeniorResearch Fellowship,hehasheldlecturingrolesatseveralosteopathicschoolsandlecturedatinternational postgraduateconferences. Aswellasbeinganenthusiasticsupporterofpreventativehealthcareatboththeindividualpatient levelandinsocietyingeneral,Alanhasalongstandinginterestintheroleofbio-psychosocialaspects ofhealthandmedicalcareandthemediatingrolethatpsychosocialstressmayplayasaneffector mechanisminthepathophysiologyofillhealthanddiseasemorbidity. PreviouslypublishedworkatteststoAlan’sfascinationfortryingtodevelopbothnoveltheoretical hypothesesandclinicalpracticalapplicationsthatcantapintosomeoftheprocessesandtechniques involvedintheenhancementofthetherapeuticvalueoftherelaxationresponse.Hewasawardedhis Masters degree in the Psychobiology of Stress at the University of Surrey and also completed an AdvancedDiplomainClinicalHypnosisandStressManagementatStaffordshireUniversity. Inadditiontohisprimaryprofessionalorganizationalmemberships,heisalsoamemberofThe BritishMedicalAcupunctureSociety,theBritishSocietyofClinicalandAcademicHypnosis(BSCAH) andaFellowoftheRoyalSocietyforPublicHealth.AlanisalsotrainedintheFertileBodyMethod. Alanisco-founderandleadclinicianatTrueHealthClinics,Cambridgeshire,andfounderofand scientificadvisortoTheStressManagementFoundation. x Foreword LikeallbranchesofChinesemedicine,traditionalgynaecologyhasalonghistory.Theearliestrecords ofgynaecologicalmedicalwritingsdatefromtheShangdynasty(1600–100BC):bonesandtortoise shellsfromthatperiodhavebeenfoundwithinscriptionsdealingwithchildbirthproblems.Thetext ‘Book of Mountains and Seas’ from the Warring States period (476–221 BC) describes medicinal plantstotreatinfertility. TheNeiJing–SuWenhasmanyreferencestowomen’sphysiologyandanatomy,aswellasthe diagnosisandtreatmentofgynaecologicalproblems.Itdescribesthefunctionoftheuterusandstates itsconnectiontotheHeartandKidneysviathebaomai(UterusVessel)andbaoluo(UterusChannel) respectively.Forexample,the‘SimpleQuestions’inChapter33say:‘Inamenorrhoea,theUterusVes- selisshut.TheUterusVesselpertainstotheHeartandcommunicateswiththeUterus;whenQirebels upwardstopresstowardstheLungs,Heart-Qicannotflowdownwardsandamenorrhoearesults’.1In Chapter47itstates:‘TheUterusChannelconnectswiththeKidneys;theKidneychannelreachesthe rootofthetongue’.2 ThatgynaecologyalreadyexistedasaspecialityduringtheWarringStatesperiodisrecordedin the‘HistoricalAnnals’(ShiJi),whichrefertothefamousdoctorBianQueasonewho‘treatsdis- easesunderthebelt’(DaiXiaYi),thatis,agynaecologist.AlthoughBianQueisnotahistorical figure, and the Shi Ji was compiled during the Han dynasty, it refers to events of the Warring States period. DuringtheHandynasty(206BC–AD220),agynaecologistwascalleda‘breastdoctor’(RuYi)or ‘women’sdoctor’(NuYi).ThefamousdoctorZhangZhongJingrefersinhiswork‘Discussionon Cold-inducedDiseases’(ShangHanLun)toapreviousbookentitled‘SeriesofHerbsforObstetrics’ (TaiLuYaoLu),whichprovesthatevenbeforetheHandynastytherewerebooksdealingexclusively withgynaecology,butallofthesehavebeenlost. The‘DiscussionofPrescriptionsoftheGoldenChest’(JinGuiYaoLueFangLun)bythesameauthor hasthreechaptersongynaecology:‘Onpregnancy’,‘Post-partumdiseases’and‘Women’smiscella- neousdiseases’.Thesechaptersdiscussdisordersofmenstruation,leucorrhoea,pregnancy,miscella- neousdiseases,andpost-partumproblems.Thesethreechaptersongynaecologyrepresentoneofthe earliest gynaecological treatises, and they formed the model upon which subsequent books werebased. The‘PulseClassic’(MaiJing,AD280)byWangShuHe,afamousdoctoroftheJindynasty(AD 265–420), describes pulse pictures and differentiation of women’s diseases in Volume 9. Wang ShuHealsoaddedawealthofcommentsfromhispersonalexperienceinthegynaecologicalfield. Forexample,hesaysthat‘TheKidneysgoverntheUterus,anditsconditionisreflectedattheChi [Rear]positionofthepulse.Ifthepulseatthisregiondoesnotfadeonpressure,itindicatespreg- nancy’.3Inanotherpassagehesaysthat‘Inpregnantwomen, asuperficial pulseaccompaniedby 11979TheYellowEmperor’sClassicofInternalMedicine-SimpleQuestions(HuangTiNeiJingSuWen),People’sHealth PublishingHouse,Beijing,firstpublishedc.100BC,p.197. 2Ibid.,p.259. 3WangShuHe1988ARevisedExplanationofthe‘PulseClassic’(MaiJingJiaoShi),withcommentarybytheFuzhouCity People’sHospital,People’sHealthPublishingHouse,Beijing,p.585.FirstpublishedinAD280. xi Foreword abdominalpainreferredtothemidlineofthelowerback,indicatesimpendinglabour’.4Thebook alsodescribesthequalitiesofthepulsebeforeanimminentmiscarriage,normalandabnormalpulses duringthepost-partumstageandpulsesinwomenwithabdominalmassesinrelationtoprognosis. Allsubsequentclassictextscontainawealthofknowledgeandclinicalinformationongynaeco- logicalandobstetricdiseases.Especiallyofnotearethe‘GeneralTreatiseontheSymptomatology andAetiologyofDiseases’(ZhuBingYuanHouZongLun,AD610)byChaoYuanFangandthe‘Thou- sandGoldenDucatPrescriptions’(QianJinYaoFang,AD652)writtenbySunSiMiao.SunSiMiao madetheinterestingobservationthatametalknifeshouldneverbeusedtocuttheumbilicalcord: fromamodernperspective,thiswasanimportantrecommendationas,ifdirty,ametalinstrument caneasilyprovokeatetanusinfection. The‘TreasureofObstetrics’(JingXiaoChanBao),writtenduringtheTangdynasty,istheearliest obstetricsbook.Thebookcontainstwelvechaptersondiseasesofpregnancy,fourchaptersondif- ficult labour and twenty-five chapters on post-partum diseases. Diseases of pregnancy discussed include morning sickness, bleeding, threatened miscarriage, miscarriage, urinary problems and oedema.Thediscussiononlabourproblemsincludesformulaeforpromotinglabour,dealingwith adeadfoetus,prolongedlabourandretentionoftheplacenta.Thediscussiononpost-partumdis- easesincludestetanus,puerperalinfections,abdominalpain,persistentbleeding,retentionofurine, lactationinsufficiencyandmastitis. DuringtheSongdynasty(960–1279)theimperialmedicalcollegewasstaffedby300people;there wereninedepartments,oneofwhichwasobstetricsandgynaecology.Thiswasprobablytheearliest medicalschooldepartmentdedicatedentirelytogynaecologyandobstetrics.Thisledtothepublica- tionofmanybooksspecializinginobstetricsandgynaecology,animportantonebeingthe‘Great Treatise ofUseful Prescriptions for Women’ (FuRenLiang Fang DaQuan, 1237)written byChen ZiMingduringtheSouthernSongdynasty.Thebookcomprises24volumes,including20chapters onmenstrualdiseases,91onmiscellaneousdiseases,10oninfertility,8on‘foetaleducation’,9on pregnancyproblems,70onpost-partumdiseasesand10onboilsandulcers.Morethan260diseases arediscussedinallwithvariousformulaeforeach.Thisbookexertedaprofoundinfluenceonthe developmentofobstetricsandgynaecologyinsubsequentdynasties. During the Yuan dynasty (1279–1368) many different medical schools of thought flourished, amongwhichthemainoneswerethoseheadedbyLiuWanSu,LiDongYuan,ZhuDanXiandZhang ZiHe.LiuWanSu(1120–1200)maintainedthatFireistheprimarycauseofdisease,andhetherefore advocatedtheuseofcoldherbsingynaecologicalproblems.Forexample,heattributedamenorrhoea toHeart-Fire. LiDongYuan(1180–1251)wasthefounderofthe’SchoolofStomachandSpleen’,whichempha- sizedadisharmonybetweenthesetwoorgansasthemainaetiologyandpathologyofdiseases.He thereforeadvocatedtonifyingtheStomachandSpleenasthemainmethodoftreatmentingynaecol- ogy,too.Inhisbook‘SecretRecordoftheOrchidChamber’(LanShiMiCang),hesaysthatprolonged deficiencyoftheStomachandSpleenleadstoamenorrhoeaandthattotreatthis,oneneedstoclear Stomach-Heat,generateStomachfluidsandtonifyQiandBlood.Hesaysthatuterinebleedingisdue todeficiencyoftheStomachandSpleen,arousingMinisterialFireoftheKidneysandcausingDamp- Heat to infuse downwards: To treat this, he advocates tonifying the Stomach and Spleen and raisingQi. ZhuDanXi(1281–1358)maintainedthat‘YangisofteninexcessandYinisoftendeficient’and thereforeadvocatednourishingYinasoneofthemostimportanttreatmentprinciples.Forexample, forproblems beforechildbirth he advisedclearingHeat andnourishing Blood.Healsoindicated HuangQin(RadixScutellariaebaicalensis)andBaiZhu(RhizomaAtractylodismacrocephalae)astwo importantherbstopreventmiscarriage.Tothisday,thesearetwoimportantherbsusedtoprevent miscarriage. ThedoctorsoftheMingdynasty(1368–1644)consolidatedandintegratedthetheoriesofthese fourgreatschoolsofmedicalthought.Manyimportantgynaecologicalbookswerewrittenduring the Ming dynasty, such as ‘Standards of Diagnosis and Treatment of Women’s Diseases’ (Zheng Zhi Zhun Sheng - Nu Ke, 1602) by Wang Ken Tang, ‘Summary of Gynaecology and Obstetrics’ 4Ibid.,p.588. xii Foreword (NuKeSheYao,1548)byXueJiand‘SummaryofFertility’(GuangSiJiYao)and‘Women’sSecrets’ (FuRenMiKe)byWanQuan. Interestingly,WangKenTangsaidthat,inordertoconceive,themanshouldclearhisHeartand controlhissexualdesiretonourishtheJing,whileawomanshouldcalmherMindandsettleQito nourishBlood. The‘CompleteWorksofJingYue’(JingYueQuanShu,1624),byZhangJingYue,hasanextensive section ongynaecologyand obstetrics thatdiscussesthe treatmentofproblems ofpregnancyand labour, leucorrhoea, breast diseases, fertility, abdominal masses and menstruation. Zhang Jing Yuerecommendedpayingparticularattentiontoregulatingmenstruationingynaecologicaldiseases. HesaidthatthekeytoregulatemenstruationistonourishBloodbytonifyingtheStomachandSpleen andcalmingthechamberofBloodbytonifyingtheKidneys.OnthequestionofwhethertheSpleen ortheKidneyswasthemoreimportantorgan,hedecidedinfavourofthelatter. DuringtheQingdynasty(1644–1911)manygynaecologicaltreatiseswerewritten.Themostnota- bleoneis‘FuQingZhu’sGynaecology’(FuQingZhuNuKe)byFuQingZhu(1607–1684). ‘FuQingZhu’sGynaecology’isunlikeanyothergynaecologybookinsofarastheauthorproposes hisownpersonal,andoftenunorthodox,ideasonthepathogenesisandtreatmentofgynaecological diseasesandhisformulaeareunlikeanyofthosefrompreviousgynaecologicalbooks.Oneofthe centralthesesofFuQingZhu’sbookisthattheKidneysarethemostimportantorganforthemen- strualfunctionastheyaretheoriginofmenstrualblood.Accordingtohim,menstrualbloodisunlike normalBlood:itisapreciousfluidderivedfromtheKidney-Jing.Ipersonallycompletelyagreewith thisview,andtheimportanceoftonifyingtheKidneysingynaecologicalproblemstomecannotbe overemphasized. Since1949thecombinationofWesternandChinesemedicinehasbeenemphasized,andmany innovativetreatmentshavebeendevised.Forexample,ectopicpregnancyisoftentreatedwithacu- punctureandChineseherbswithoutrecoursetosurgery;acupunctureisusedinbreechpresentation ofthefoetus;Chineseherbsareusedinthetreatmentofmyomasandcervicalcarcinoma,andsoon. SincethemajorcollegesofTraditionalChineseMedicinewereestablishedin1956,manymodern gynaecologytextbookshavebeenpublishedandtheancientonesreprinted. OfparticularinterestisthetheoryofthefourphasesofthemenstrualcycleintroducedbyDr.Xia GuiCheng;thisisatheorythatcleverlyintegratestheChineseviewofYinandYanginthemenstrual cyclewiththeWesternviewofoestrogenandprogesteroneandthefollicularandlutealphases. ThetreatmentoffemaleinfertilityhasalwaysoccupiedamajorplaceinChinesegynaecology.From aphilosophicalandsocialperspective,thiscouldbeattributedatleastinparttotheConfucianviews onfamilyandsociety.ConfucianphilosophyhadahugeinfluenceonChinesemedicine,aninflu- encethatinmyopinionisnotrecognized.MostpractitionersthinkthatChinesemedicineisDaoist and that the Nei Jing is a Daoist text. In fact, the whole cultural background of the Nei Jing is completelyConfucianandpartlyLegalist.Forexample,theviewoftheInternalOrgansas‘ministers’ andtheHeartas‘ruler’iscompletelyConfucian(Chapter8oftheSuWen).TheDaoistswouldnever makesuchacomparisonbecausetheydislikedallpoliticalpowerandgovernmentstructures.Ifwe readChapter80oftheDaoDeJingwecanseethedescriptionoftheidealDaoistsociety:averysmall communitywhereonehearscockscrowfromacommunitynextdoor,buttheresidentsneverfeelthe needtogothere.Chapters18,19and38oftheDaoDeJingarestingingattacksonConfucianphi- losophy,evencallingitthe‘greathypocrisy’. WeshouldalsorememberthattheNeiJingwaseditedthreetimesbyImperialCommitteesduring the Song dynasty (960–1279), which saw the complete triumph of the Confucian ideology that remainedtheonlyacceptedstateideologydowntopresenttimes.Iwouldevenarguethatmanychar- acteristicsofthepresentregimearemoreConfucianthanMarxist.Ofcourse,thatisnottosaythat therearenoDaoistinfluencesontheNeiJing;thereare.TheverywordsuinthetitleSuWenreflects thetypicalDaoistidealofbeing‘unadorned’likerawsilk,thatis,‘simple’.Daoistsadvocatedsimplic- ityoflifestyleandshunningofpoliticalpower. Goingbacktowomen,fertilityandchildren,Confucianistsattachedhugeimportancetochildren asaperpetuationofone’slineageandalsoascaretakersofthegravesoftheirparents.Filialpiety(xiao) isafundamentalcornerstoneofConfucianphilosophy.Ithinkthisisatleastapartialexplanationof thehugeimportancegiventofertilityingynaecologybooks. Asweallknow,Chinesemedicinecanbeveryeffectiveinthetreatmentofinfertility.However,with ourpatients,wearefacedwithnewchallengesthatancientChinesedoctorsdidnothave,andthatis xiii
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