Unexplained Infertility. Report of Findings

Posted on January 31, 2024

Report of Findings:

Unexplained Infertility

Written by Shabnam Pourhassani, LAc, QME, DACM, FABORM

Citation: Pourhassani, Shabnam, Report of Findings: Unexplained Infertility. July 6, 2021. http://www.acupunctureinsteadofsurgery.com/report-findings-unexplained-infertility/

July 6, 2021

Abstract: Scientific knowledge and diagnostic screenings have limitations. Unexplained infertility is a diagnosis provided to couples trying to conceive who have been diagnosed with infertility, when current diagnostic screenings cannot provide a biomedical explanation why. The practice committee guideline of the American Society of Reproductive Medicine states that the treatment of unexplained infertility by necessity is empiric. Based on empirical clinical outcomes I recommend acupuncture for this diagnosis.

Keywords: Unexplained infertility, reproductive acupuncture, infertility

Disclaimer: This Blog is published for licensed healthcare professionals who have education in Chinese medicine and reproductive medicine. This blog is not written for consumers, or infertile patients to make medical decisions.

Current Research:

I conducted a literature search in the journal; Fertility and Sterility using the keyword; unexplained infertility, and searched for published articles within the last 12 months (July 2020-July 2021).

The diagnosis of unexplained infertility is provided after 1 to 3 years of trying to conceive (TTC) without a successful pregnancy, and when routine tests such as blood work, tubal patency, and sperm analysis are “normal”. About 15%-30% of couples with TTC are diagnosed with unexplained infertility after 1 year of TTC (Ombelet et al., 2020). About 30% of couples with unexplained infertility have a spontaneous conception a year after diagnosis. (Hunault et al., 2004). Advanced paternal age reduces the success of IVF/ICSI for couples with unexplained infertility (Mohamed et al., 2020).

The practice committee of the American Society of Reproductive Medicine published a guideline for the diagnosis of unexplained infertility in 2020. The guideline is based on extensive literature review from 1968-2019. The title is Evidence based treatment for couples with unexplained infertility: a guideline. The guideline provides evidence-based recommendations for unexplained infertility regarding effectiveness and safety. However, they conclude that the treatment of this diagnosis is “by necessity empiric”.

The Merriam-Webster dictionary defines empiric as; one who replies on practical experience (Merriam-Webster, n.d.). The Collins dictionary of medicine defines empirical treatment as; “treatment given without knowledge of the cause or nature of the disorder and based on experience. Medical treatment that is given on the basis of the doctor’s observations and experience”.

Chinese Medical Theory: The diagnosis of unexplained infertility requires a deeper evaluation by a reproductive acupuncturist. An acupuncturist does not solely rely on the limited findings of a sperm analysis, lifestyle factors, or drugs (legal, or illegal) which may reduce the fertility potential of a man.

Reproductive acupuncturists, and general acupuncturists are concerned with the function of all systems, and the preconception health and age of the man’s parents. If the man was born to a mother who is of advanced maternal age, or who was not in the best of health, or who had many children; her jing may have been depleted by the time she had this child, who now is unable to reproduce.

The jing of the mother can loosely be compared to mitochondria, the egg gives the offspring their mitochondria. This would be manifest with low cellular energy (ATP), and reduced chance of sperm fertilizing an egg, which would lead to no embryo, no pregnancy, and no baby. Unexplained infertility requires an evaluation of the male partner for Chinese medicine pattern differentiation and treatment.

The male partner could be present with any Chinese medical pattern diagnosis such as Kidney Yang deficiency, Kidney Yin deficiency, Spleen deficiency, Liver Fire, and so on.

The female partner also requires an in depth evaluation prior to being provided acupuncture for unexplained infertility. It is baffling how many lay people think they receive acupuncture for infertility without a consultation, or evaluation, and decide when, and how often they get acupuncture. Acupuncture is not a self-directed therapy, it requires years of education and infertility specialization.

The female partner will be asked some of the same questions to access function, as the male:

Sensation of Heat, or Cold (ie: are you always cold?)
Abnormal or Excessive Sweating
Issues with Head & Face (pain, swelling, numbness, etc.)
Pain (anywhere in the body)
Frequency and quality of stool/urine
Thirst/Appetite/Taste/Cravings
Questions regarding sleep
Questions regarding emotional state/stress
Coital frequency
Current supplement use
Current and past pharmaceutical use
Current and past recreational drug use
Sexual practices

Questions specific to male:

Libido
Erections
Ejaculation
History of STDs
Occupational infertility risks

Questions specific to female:

Gynecological history
Ovulation
Cervical mucus
Libido
History of STD’s

A woman with unexplained infertility can present with Liver Qi stagnation, Spleen Qi deficiency, Stomach Fire, and any other Chinese medical pattern diagnosis. Women with unexplained infertility rarely present with Kidney Yin deficiency, or Kidney Yang deficiency. Kidney Yin, or Yang deficiency usually correlates to the biomedical diagnosis of diminished ovarian reserve, premature ovarian insufficiency, not unexplained infertility.

Treatment Plan:

Unexplained infertility, based on my empirical clinical findings, responds well to the treatment plans outlined here:

Treatment for male: If, after an evaluation, I deem it appropriate for the male partner to receive acupuncture the protocol is; acupuncture twice a week for 6 weeks. If the male is diagnosed with Kidney Yin, or Kidney Yang deficiency; herbal medicine will be required to take for 3 months. If acupuncture is deemed unnecessary (the male is under 40, is in perfect health, does not take any over the counter drug regularly, or any pharmaceuticals), he will be provided with lifestyle advice which covers nutrition, how much alcohol he may drink, why marijuana is not recommended to smoke, or ingest, and tips of how to deal with the stress of having sex on a schedule if necessary.
Treatment for females: is based on pattern differentiation. Herbal medicine is a must if the female has Kidney Yin, or Yang deficiency (as long as there is no herb-drug interaction). Or, if there has been a recent miscarraige; herbs are recommended as well. For all other pattern diagnosis herbs are not recommended per my outcomes of over 12 years. Women are also provided lifestyle, and nutrition advice (no salads, juicing, or ice). Acupuncture is provided twice a week, for 3 months.
Acupuncture points: for men and women with unexplained infertility: SP6, K3, LV3, ST29, R3
Moxibustion: is used if there is a cold pattern, or yang deficiency. Moxibustion for unexplained infertility is used on K3, SP4, SP6, or R3 depending which point feels cold upon palpation.
Patients willingness to participate in recommendations: The patient is provided the information and can choose to start treatment, or decline treatment.
Patients who are non compliant are subject to discharge. Most infertility patients are very motivated and follow directions. Especially, when IVF has failed once, or twice.

Alternative Approaches:

Do not pursue any medical treatments.
Attempt to adopt. Adoption is expensive.
3-4 rounds of Intrauterine insemination (IUI)
When IUI has failed; IVF is recommended.
Naturopathic doctors may have recommendations as well, such as seed cycling, supplements, nutritional advice, and lifestyle recommendations.

Biomedical Considerations:

There are no biomarkers that distinguish the diagnosis of unexplained infertility. However, we have to make sure that the patient does not get chlamydia which may block the tubes. This is why it is important to know what sexual habits the patients have.

Community Resources: Support groups (in person/online), Resolve is an infertility support group, the American Society of Reproductive Medicine has resources.

Prognosis:

Unexplained infertility is the easiest biomedical infertility diagnosis to treat as a reproductive acupuncturist. Unfortunately, patients choose assisted reproductive technology (ART), such as IUI, or IVF, over acupuncture. What may be lacking in the literature review by the ASRM practice committee is acupuncture. This may be lacking as there are no studies on the effect and safety of acupuncture for unexplained infertility. If reproductive acupuncturists would focus on this diagnosis, and collect data it may alter the course of reproductive history with the recommendation of acupuncture as a first line therapy for unexplained infertility. As of now, I only see American Acupuncturists interested in providing adjunct care for assisted reproductive medicine, and not acupuncture and Chinese Medicine as monotherapy. Acupuncture as monotherapy for unexplained infertility deserves clinical research. Acupuncture is less expensive than IVF. Acupuncture additionally may reduce depression, anxiety and chronic stress in the infertile population, thus having multiple benefits.

Summary of key learnings: I learned about research findings in regards to unexplained infertility and advanced paternal age. This will help with educating patients. Patients believe that the treatments they receive are based on hard scientific findings, and not on empirical evidence. They do not know about the outcomes of advanced paternal age on infertility treatments, or infertility in general. The women think the responsibility and fault of failed IVF cycles are due to their age only. It is harmful for individuals facing infertility not to to be properly informed.

Thank you for reading. If you have any questions or comments please email: Shabnam.Pourhassani@gmail.com .

References

Hunault, C. C., Habbema, J. D., Eijkemans, M. J., Collins, J. A., Evers, J. L., & te Velde, E. R. (2004). Two new prediction rules for spontaneous pregnancy leading to live birth among subfertile couples, based on the synthesis of three previous models. Human Reproduction, 19(9), 2019-2026. https://pubmed.ncbi.nlm.nih.gov/15192070/

Mohamed, A., Khalafalla, K., Majzoub, A., & Al Badr, M. (2020). THE EFFECT OF PATERNAL AGE ON ICSI OUTCOME IN UNEXPLAINED INFERTILITY. Fertility and Sterility, 114(3), 396. https://www.fertstert.org/article/S0015-0282(20)31916-6/fulltext

Ombelet, W., McNally, A., Ledger, W., Doody, K., & Farquhar, C. (2020). Should couples with unexplained infertility have three to six cycles of intrauterine insemination with ovarian stimulation or in vitro fertilization as first-line treatment? 114(6), 1141-1148. https://www.fertstert.org/article/S0015-0282(20)32543-7/fulltext

Merriam-Webster. (n.d.). Empiric. In Merriam-Webster.com dictionary. Retrieved July 6, 2021, from https://www.merriam-webster.com/dictionary/empiric

Empirical treatment. (n.d.) Collins Dictionary of Medicine. (2004, 2005). Retrieved July 6 2021 from https://medical-dictionary.thefreedictionary.com/empirical+treatment