Int J Clin Exp Med 2018;11(4):4336-4342

www.ijcem.com /ISSN:1940-5901/IJCEM0057203

Case Report
Traditional Chinese medicine combined with
acupuncture improved diminished ovarian reserve
Lin Su1*, Hai Xu2*, Qing Tong3, Zhe Jin3, Hongmei Liu1, Yunbo Li4
1
Rehabilitation Hospital, National Research Center for Rehabilitation Technical Aids, Beijing 100176, P. R. China;
2
Department of Obstetrics and Gynecology, Huangjiahu Hospital, Hubei University of Chinese Medicine, Wuhan
430065, P. R. China; 3The Eastern Hospital of Beijing University of TCM, Beijing 100086, P. R. China; 4Gynecologi-
cal Clinic, Beijing University of Chinese Medicine Third Affiliated Hospital, Beijing 100029, P. R. China. *Co-first
authors.
Received January 12, 2017; Accepted January 28, 2018; Epub April 15, 2018; Published April 30, 2018

Abstract: This study reported a 35-year-old female case with DOR was referred to this study and had a 3-year history
of infertility. This case had failed three times to be pregnant by the treatment of multiple clomid cycles and IVF. Then,
she came to the clinic in The Third Affiliated Hospital of Beijing traditional Chinese medicine University for seeking
the TCM therapy. The Traditional Chinese Medicine (TCM) treatment-Chinese herbs combined with acupuncture-
lasted from April 2014 to July 2014. The main outcome was the improvement of the patient’s reproductive hormone
panel, including FSH level, estradiol level, and AFC amount; in addition a pregnancy outcome was desired. After
receiving the 3-month TCM treatment, the patient had great improvement in her reproductive hormone panel, the
level of FSH was decreased from 12.3 mIU/mL to 6.7 mIU/mL and the amount of AFC was improved from 1-2 to 6-8
total. When she returned to receive the treatment of IVF auxiliary fertility technology, she was successfully pregnant.
The therapy of Chinese medicine combined with acupuncture was effective and practicable in IVF auxiliary fertility.

Keywords: Infertility, diminished ovarian reserve, acupuncture, chinese medicine, the therapy of nourishing the
kidney and dredging the stagnation of liver

Introduction Acupuncture as the first choice of IVF auxiliary

fertility technology.
Infertility, caused by diminished ovarian reserve
(DOR), was mainly resulted from the endocrino- The diagnosis of female infertility was based on
logical imbalance. There are some typical mani- the following criterias: woman had no concep-
festations, including follicle stimulating hor- tion for 1 year when she was under 35-year-old
mone (FSH) rising and antral follicle count (AFC) and woman had no conception for 6 months
decreasing for women under 40-year-old, preg- when she was 35 or beyond 35-year-old. In gen-
nancy ratio under 5%, miscarriage ratio beyond eral, such woman firstly turned to assisted con-
75%. For those infertility females, the IVF-ET ception before they came to fertility specialists.
technology is quite promising [1,2]. However, The most common solution from gynecologist
the success rate is still low, and the ovarian is to induce ovulation with drug followed by in
reserve function sharply diminished caused by vitro fertilization. Clomid, the medicine used to
excessively stimulating ovarian for repeatedly induce ovulation, should be taken once a day
inducing ovarian and transplanting embryo. for 5 days. It is the fifth day of the menstrual
Compared with the IVF-ET technology, Chinese cycle to start taking clomid. Clomid is thought
medicine and acupuncture display following as a selective estrogen-receptor modulator, but
advantages: improving the level of FSH and the its mechanism of action is not completely
amount of antral follice, elevating the ratio of understood. It can block the E2 receptor in the
pregnancy, and decreasing miscarriage ratio. hypothalamus, then the releasing of gonadotro-
Now, more and more females with DOR accept- pin-releasing hormone (GnRH) is triggered to
ed the treatment of Chinese medicine and signal the anterior pituitary to release FSH. The
 TCM combined with acupuncture in treatment of DOR

increased FSH in circulation will signal one or dredging the stagnation of liver combined with
more follicles in ovaries to mature [3-5]. acupuncture. This DOR case was very common
in the infertility acupuncture specialty practice.
It has more than 2000 years histroy that the Before they received the TCM treatment, they
Traditional Chinese medicine and the acupuc- often had failed several times to be pregnant
ture had been applied for the treatment of by many consecutive clomid cycles and IVF.
female infertility in China. Recently, studies
indicated that the acupuncture can improve the Case report
outcome of assisted reproductive technology
[6]. There is no descriptions for DOR disease in A 35-year-old woman with infertility caused by
the Ttraditional Chinese medicine. However, DOR came to the clinic to see a doctor in April
the reproductive life-cycle has been elaborately 2014. The patient was 165 cm high and 60 kg
described more than 2000 years ago in Huang weigh. She went through the menarche at
Di Nei Jing (The Yellow Emperor’s Canon of 14-year-old. Her menstrual cycle was 23-24
Internal of Medicine), a classical medicine days. The menstrual bleeding of her mentrual
ancient text in China, in a close pattern of mod- cycle lasted for 4 days in recent three months.
ern biomedicine. In the ancient text, a natural The menstrual flow was moderate. At the begin-
shift in female fertility had been defined as ning of her cycle, the menstrual blood was thin,
7-year interval, which is close to what is cited in fresh, and red or pale red. On the fourth day of
current biomedical literatures [7]. her cycle, the menstrual blood tapered off and
became watery and pale brown. There was no
In Chapter 1 of the Huang di Nei Jing, there are
clot in her menstrual blood. The mild-to-moder-
two key opinions on the reproductive lifecycle:
ate cramping often appeared during the 5 days
the kidney was thought as the governor of
before her menses or the first 2 days of the
reproduction and reproductive potential was
menstrual cycle. In addition, there were also
described with 7-year interval. The fertility of
other symptoms to occur during the 5 days
28-year-old was defined as “apex” and entered
before menses, including irritability, bloating,
the beginning of the vacuity shift. This is quite
and breast tenderness. By determining with an
close to the result drawed from the biomedical
ovulation-predictor kit, she was predicted to
statistics observation, and there is only one
ovulate on CD 10 or 11. The cervical fluid,
year difference in their predicted age of the
which naturally appears on the normal female,
beginning of the subtle decline of ovarian
did not occur, and she had the manifestation of
reserve. In Fu Qingzhu Gynecology work, anoth-
vaginal dryness or dyspareunia. She not only
er gynecology publication, the female with DOR
had a smoking history but also drank alcoholic
was suggested to be referred to woman with
beverage less than 7 times a week.
the menopause who is under 49-year-old.

In Traditional Chinese Medicine, the governing Three years ago, her left Fallopian tube had
role of Kidney in reproduction is quite critical been cut off because of the Ectopic pregnancy.
for health fertility. On clinic, females undergo- She had no family history of the premature
ing in vitro fetilization (IVF) were usually diag- menopause. In the fall of 2013, she received
nosed as kidney pathologies by the Traditional the treatment of three consecutive clomid
Chinese Physician. In terms of the TCM theory, cycles with IVF prescribed by a woman’s health
kidney had to endure some etiologic factors nurse–practitioner (NP). Finally, she was not
like repeated reproductive-medicine interven- pregnancy. At the end of 2013, her FSH level
tion, and in turn those factors would deplete was 12.3 mIU/mL, and the AFC amount was 1-2
kidney and ultimately had a negative impact on bilaterally. She took 100 mg of clomid every
reproductive outcome [8]. Based on the theory month and generally had 1 primary follicle dur-
of Traditional Chinese Medicine, some exoge- ing the ovulation. She was suggested to receive
nous treatments, including multiple clomid IVF by the NP one day. There was no informa-
cycles and IVF, can deplete kidney blood and tion of her endometrial thickness during the
yin, and exert the negative effect on the repro- insemination. Except for that she was told her
ductive lifecycle. ovaries small by the NP during the ultrasound
examination, there was no other information. In
This article reported a DOR case treated with her medical record, her Fallopian tubes had
the TCM therapy of nourishing the kidney and been recorded to be blockages, and her uterus

4337 Int J Clin Exp Med 2018;11(4):4336-4342

 TCM combined with acupuncture in treatment of DOR

to be abnormal. For her husband, the result of According to the cycle phases, the treatment of
the sperm analysis was normal, including Chinese herb and Weekly acupuncture was tai-
sperm counting and motility. There was no lored for her. The needles used were 0.20×30
available morphology information came from mm, Spring type (DBC, Korea) on body points,
any morphology test. and 0.16×15 mm, D-type (Red Seirin, Japan)
needles without guide tubes on the ears.
This patient was pale complexion and soft-spo- Chinese herbal medicine (Kaiser Pharma-
ken. When she spoke her fertility challenge ceutical Co., Ltd., Taiwan) was administered
accompanied by a series of demeanor, she from April through July, 2014. All point func-
became weepy, desperate, and frustrated. She tions were determined according to A Manual
often felt fatigued and moderately-to-highly of Acupuncture, and all herb functions were
stressed. She often lay in lethargy and was dif- determined according to Chinese Herbal Med-
ficult to wake up. Gas and bloating after meals; icine: Formulas and Strategies, 2nd ed.,16
sugar cravings; daily bowel movements that unless otherwise noted. When selecting points
were occasionally loose or became urgent and/ for treatment, great emphasis was placed on
or crampy with stress; mild-to-moderate anxi- changes in pulse quality when acupuncture
ety that manifested as chest palpitations, points were palpated. If the pulse improved
chest tightness and, shortness of breath; thirst; when the point was palpated, it was selected
nocturia once nightly; frequent urination; no for that treatment. All points were needled to
night sweats except for taking clomid; dull, elicit De Qi with a lifting thrusting technique
“achey” headaches every 2 weeks; occasional and manipulated with an even rotation tech-
dizziness; and a neutral core body temperature nique.
with cold hands and feet. Her pulses, overall,
were slow and deep. On her left side, the pulse Herbal formula. The Yi Jing Zi Gui Yin was
was especially deep, soft, and weak in the guan administered by combined with the premixed
and chi positions. On her right side, the pulse granular formula. This formula was prescribed
was soft and weak in the chi position. Her to Kidney-nourishing Dispersing depression of
tongue was pale purple, swollen and wet. the liver therapy. Formula base included:
Duzhong, Shudi, Tusizi, Chaihu, Baishao, Shan-
Her TCM diagnosis were: 1) Kidney Yang and yao, Baizhu, Dangshen, Huangqi, Maidong,
Essence (Jing) deficiency, as evidenced by her Suanzaoren. These Herb were refined into
low energy; frequent urination; nocturia; and decoction and granules. The dosage was 10 g
weak, deep, soft pulses (according to poor twice daily, dissolved in warm water to be taken
response to medications, small ovaries, and on CD 5-24 only.
infertility also indicate this diagnosis), 2) Liver
Acupuncture treatments
Qi stagnation, evidenced by frustration/irrita-
bility, breast tenderness, bloating, and premen- Follicular Phase (CD 5-11): During this phase,
strual cramping. Yin and Blood become most abundant. The
treatment goals were to benefit the Kidney,
Treatment nourish Yin and Blood, circulate Qi and Blood,
and calm the Shen. Acupuncture was per-
According to this patient’s initial consultation, formed twice per week, alternating front and
she was fistly recommended to have a 3-month back treatments, to support follicle maturation
break from any reproductive interventions. and nourish Yin and Blood. Acupuncture was
Secondly, she was suggested to have a full performed on her ear and manually on other
reproductive physical examination for her and parts of her body.
her husband in the biomedical opinion, because
of the failure of conception after three attempts Six to eight body points, with no more than five
with clomid. In order to know what her hus- ear points, were selected. Points were selected
band’s sperm morphology was, the third sug- based on the patient’s pulse and presentation
gestion was to evaluate male factors. The on the day of treatment. Acupuncture of the ear
patient agreed with the first treatment plan and included points involving Endocrine, Uterus,
declined to follow the last two recommend- FSH, Shenmen, Liver, Kidney, or Heart areas
ations. as follows: Guanyuan CV 4 (Infant’s Palace)-to

4338 Int J Clin Exp Med 2018;11(4):4336-4342

 TCM combined with acupuncture in treatment of DOR

Table 1. Index before and after treatment level was reported to be 8.7 mIU/mL in July
Index Pre-treatment Post-treatment 2014 and her AFC amount was reported to be
FSH (mIU/ml) 12.3 8.7 8-9 on each side. Then, She was prescribed to
take 100 mg of clomid during CD 5-9. She was
AFC (biatertlly) 1-2 16-18
instructed to return for an ultrasound examina-
tion on CD 12. The result of examinating was
address Yin, Essence, Qi, and Yang; regulate that 1 primary follicle had been developed and
the Uterus; tonify the Kidney; and calm the its diameter was 20 mm. Her endometrium was
Shen; Sanyinjiao SP 6-to nourish Blood, circu- 10 mm thickness and trilaminar. Based on
late Qi, and calm the Shen; Qichong ST 30-to these results of examintation, she was injected
promotes Kidney Essence, improves Middle a human chorionic growth hormone (hCG) to
Jiao function, and regulate Qi and Blood in the trigger the ovulation and was instructed to
lower abdomen; Zi Gong M-CA-18-to raise and come back for an IVF after 36 hours. She
regulates Qi around uterus and ovaries; Zusanli received the IUI on CD 14. And pregnancy result
St 36-to nourish the Blood and Qi; Taixi KI 3-to was gotten. Now, She has successfully con-
tonify the Kidney and benefit the Essence; ceivedfor 34 weeks (Tables 1-3).
Taichong LV 3-to circulate Qi; Neiguan PC 6-to
calm the Shen, open the chest, harmonize the Discussion
Stomach, and regulate the Blood; Lieque LU 7
and Zhaohai KI 6-Ren Mai confluent points. Based on the academic thoughts of Fu Qingzhu
Ovulation Phase (CD 12-17): In this Phase, Yin and combined with current pathological char-
transforms to Yang through the assistance of acteristic and surrounding, the therapy of nour-
the Qi dynamic in the ovulation phase. ishing the kidney and dredging the stagnation
Treatment goals during this phase were to cir- of liver was established. In the publication of Fu
culate Qi and Blood, nourish the Heart, calm Qingzhu Gynecology, the female with DOR was
the Shen, promote ovulation, and tonify the suggested to be referred to woman with the
Kidney. Six to eight points selected from the fol- menopause who is under 49-year-old, and it
lowing: Zusanli ST 36-to tonify Qi, which may was considered that the menstrual was closely
promote ovulation indirectly by supporting the related with kidney, tiangui, Ren, du and vis-
transition to Yang; Hegu LI 4/Taichong LR 3-to cera. In such environment, including life sur-
move Qi to promote release of eggs; Guanyuan rounding, natural and humanities environment,
CV 4-to regulate the Uterus, tonify the Kidney, modern woman’s mind was nervous and body
and calm the Shen; Neiguan PC 6-to relax the was fatigue. More seriously, they often were
cervix and calm the Shen. suffered from emotional stimulation which was
Luteal Phase (CD 18-Onset of Menses): In this long-term and exceeded over the tolerance.
Phase, Yang becomes most abundant. The The aforementioned situations would lead to
treatment goals were to benefit the Kidney, the following outcomes, such as the imbalance
support Kidney Yang by nourishing Qi and the of Yin and Yang, the disorder of Qi and Blood,
Blood, raise Qi, circulate Liver Qi, and calm the the dysfunction of viscera, the insufficiency of
Shen. This case required Yang support, through kidney-Qi, the stagnation of Qi, and the stasis
supplementation for the Qi and Blood. Baihui of meridians and collaterals. Its pathogenesis
GV 20-to raise Yang/Qi and clears the mind; was the deleption of edema due to dysfunction
Sishenchong M-HN-1, with Baihui GV 20-to of kidney and the failure of producing menstru-
calm the Shen; Zusanli ST 36-to support Qi ous blood caused by the stagnation and reten-
(and treat nausea with Neiguan PC 6); Fuliu KI tion of kidney meridian, which were resulted
7-to tonify Kidney Yang and regulate sweating; from the stagnation of liver and spleen and
Neiguan PC 6-to calm the Shen and nourish the heart meridians, not the deficiency of liver-kid-
Blood. ney. Based on the theory of meridians and col-
Results laterals, the pointer therapy was defined as the
method which was to make meridians-collater-
The case had been treated for 3 months with als, Zang-Fu organs, and Qi and blood dredging
the treatment plan prescribed above, From the for achieving the therapeutic target by pushing
follow-up phone call with the patient, her FSH the points. During the ovulation period and the

4339 Int J Clin Exp Med 2018;11(4):4336-4342

 TCM combined with acupuncture in treatment of DOR

Table 2. Chinese medicine symptoms, signs scale

Degree
Symptoms, signs Coefficient
0 1 2 3
Menstrual cycle 4 Cycle regular Menstruation in advance, cycle The cycle of 46-55 days The cycle of 56 days or
28-35 days 21-27 days; menstrual delay, the after the delay more
cycle of 36-45 days menstrual delay
Menstrual volume, menstrual color 4 Normal Menstrual volume for the previous Menstrual volume for the Color dark menstrual vol-
2/3, color dark red previous 1/2, color dark ume for the previous 1/3,
color purple or light
Lumbardebility 2 No Occasional Intermittent appear Sustain
Breast pain 2 No Occasional Intermittent appear Sustain
Dmotional depression or irritability 2 No Occasional Intermittent appear Often affect the normal life
Dizziness and tinnitus 1 No Occasional Intermittent appear Sustain
Heel pain 1 No Occasional Intermittent appear Sustain
Sexual hypoactivity 1 No Occasional Intermittent appear Often affect the normal life
Chest discomfort 1 No Occasional Intermittent appear Sustain
Fatigue 1 No Occasional Intermittent appear Sustain
Typical tongue and pulse 2 No Low Medium High

4340 Int J Clin Exp Med 2018;11(4):4336-4342

 TCM combined with acupuncture in treatment of DOR

Table 3. Chinese medicine symptoms,signs score table outcomes in patients with DOR-even
Scores before Scores after with pharmaceuticals and reproduc-
Symptoms, signs tive technology-are substantially
treatment treatment
Menstrual cycle 4 0 lower than other populations with
the infertility diagnosis.
Menstrual volume, menstrual color 12 4
Lumbardebility 4 0
TCM fertility specialists frequently
Breast pain 2 0 treat those patients who had under-
Dmotional depression or irritability 4 0 went several rounds of clomid- or
Dizziness and tinnitus 2 1 would undergo- the round of clomid.
Heel pain 3 0 It is important to recommend the
Sexual hypoactivity 3 0 second suggestion to them who had
Chest discomfort 0 0 obviously failed to have conceived
Fatigue 3 0 through medication intervention
Typical tongue and pulse 4 0 after finishing three using cycles of
clomid. In addition, it is a challenge
that the Chinese herbal therapy was
post menstrual period, such points pushing used as an adjuvant of clomid, because
could enhance the effection of Chinese herb on Chinese herbs might promote clomid inter-
dredging stagnation and smoothing collaterals. ventions.
If liver and spleen were smooth, heart and kid-
ney were harmonious, the edema due to dys- Of course, another result is that the pregnancy
function of kidney was plenty, and the uterus still does not appear for those patients who
was sufficient, the pregnancy would form. took the additional three cycles of clomid after
being treated for 3 months by the TCM therapy.
In theory, the 3-month TCM treatment can However, their test results on the ovaries and
improve reproductive outcomes as for the fur- the uterus, especially FSH level and follicle
ther biomedical interventions [9]. The TCM amount, had obviously been improved. More
treatment not only can make the folliculogene- further research should be performed to inves-
sis cycle normal, but also can decrease FSH tigate what and how acupuncture and Chinese
level and increase AFC amount [10, 11, 8]. That herbs affect on ovarian physiology.
is to say, the TCM treatment can increase the
Conclusions
ovarian reserve. Then, she was so wellbeing
that she could receive biomedical in vitro fertil- Clomid may not be ideal for all patients with
ization (IVF). DOR [12]. In this study, the patient had failed to
have a pregnancy by three clomid cycles before
In TCM opinion, it was problematic for female’s she was treated with the 3-month treatment of
reproductive health to continued use clomid TCM. At the end of the TCM treatment, her FSH
which might exhaust Yin and stagnate Qi. level had been reduced and her AFC amount
Patients, who are Yang Deficiency, will respond had been improved, which implies that her ova-
best to this medication, while those patients, ries reserve have been greatly improved.
who are Yin and/or Blood Deficiency, or Qi However, she was still unable to conceive when
Stagnation (just as the case in this article) will she underwent another three cycles of clomid.
respond quite poorly, or even have been shown It is an exception and very rare. Now, there is no
many adverse-effects. Taking clomid for sever- more evidence to illustrate it. More further
al consecutive months, the latter patient will research should to be performed to discern
have several results, such as further depleted which patient population would benefit best
Kidney, damaged Yin, and engendered Empty from several consecutive clomid intervention.
Fire. The above is just the response of the case In addition, ideal treatments for patients with
in this study to repeated usage of clomid. In DOR should be developed , including integra-
brief, the most common manifestations were tive treatment strategy combined with assisted
the poor development of follicular and the reproductive techniques, acupuncture, and
increased night sweats. Favorable reproductive Chinese herbs.

4341 Int J Clin Exp Med 2018;11(4):4336-4342

 TCM combined with acupuncture in treatment of DOR

Acknowledgements [5] Practice Committee of the American Society

for Reproductive Medicine. Aging and infertility
We would like to thank patient for participation in women. Fertil Steril 2006; 86: S248-252.
in this study. We deeply appreciate the time [6] Manheimer E, Zhang G, Udoff L, Haramati A,
and critical comments of the editor and anony- Langenberg P, Berman BM, Bouter LM. Effects
mous reviewers for improving the quality of this of acupuncture on rates of pregnancy and live
paper. This study was supported by Beijing birth among women undergoing in vitro fertili-
Municipal Science and Technology Commission sation: systematic review and meta-analysis.
BMJ 2008; 336: 545-549.
(Z131107002213140).
[7] Wu L, Wu Q. The Yellow Emperor’s Canon of In-
ternal Medicine. Beijing: China Science and
Disclosure of conflict of interest
Technology Press, 1997.
[8] Li L, Jin Z, Li, YB, Li LY, Zhu XJ. Effects of Wuyu
None.
decoctiong drug-containing serum on signal
transduction pathway of ERK1/2 MAPK in rats’
Address correspondence to: Yunbo Li, Gynecological
ovarian granular cells. Beijing Zhongyiyao
Clinic, Beijing University of Chinese Medicine Third
2013; 32: 911-912.
Affiliated Hospital, Beijing 100029, P. R. China. [9] Tang Y, Li YB, Wu YH, Tong Q, Yang DX, Jin Z.
Tel: +8618672779388; E-mail: ybllll558@sina.com; Clinical efficacy study on PCOS Treated bynour-
Hongmei Liu, Rehabilitation Hospital, National ishing the kidney and dredging the stagnation
Research Center for Rehabilitation Technical Aids, of liver. Beijing Zhongyiyao 2012; 31: 521-523.
Beijing 100176, P. R. China. Tel: +8618672779388; [10] Li YB, Li L, Mao YR, Pan X, Su L, Zhang YD.
E-mail: 930627227@qq.com Professor Jin zhe experience in treatment of
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