seattle acupuncture is an art form designed to balance the body. It restores harmony to the physical, mental and emotional aspects of the body.
What is qi ?
qi —also spelled chi or ki and often pronounced "chee" like in cheese— is a universal energy present in our world. qi flows in the human body in set paths called channels, much the way water flows in a river. These channels flow longitudinally from the hands and feet to the head in both directions up and down. seattle acupuncture uses fine hairlike needles to control the flow of qi .
acupuncture needles stimulate flow, sedate flow, remove blockages, and similarly treat pathogens like cold, heat, damp, phlegm, wind, etc. Chinese herbs often supplement the seattle acupuncture treatment. The most typical treatment is ready-to-mix herbal granules added to hot water and consumed daily between acupuncture treatments .
The acupuncturist uses her diagnostic skill to assess the channels and organs in the body and selects seattle acupuncture points to restore balance.
Traditional Chinese Medicine is based on centuries of observation. The details of daily life serve as an entryway to diagnosis so a typical intake includes questions about eating sleeping, exercise, work and relationships. The tongue body and tongue coating are examined in an seattle acupuncture appointment. The pulse is assessed on the right and left wrist in three different places.
A Typical Appointment
A typical appointment lasts about fifty minutes and costs $80 per treatment. Patients often report feeling rejuvenated and enlivened by the treatment. A series of treatments is usually required to balance the body. If you do not see an improvement in six treatments, a different healing modality may be recommended.
Traditional Chinese Medicine offers much to the woman as a gynecological art.
Using seattle acupuncture and herbs can be effective for regulating Menstruation .
Short or long cycles, pain and PMS are often treatable with Traditional Chinese Medicine . In addition, the medicine assists in improving seattle fertility , maintaining pregnancy, preparing for labor and delivery, and caring for the mother and child postpartum.
Studies show improved seattle fertility with acupuncture. Menopausal women also benefit form the regulating aspects of seattle acupuncture and herbs.
Kathleen has been in private practice as an acupuncturist and Herbalist since 2002. She specializes in seattle fertility , facial rejuvenation and the treatment of various illnesses. She is currently studying “Infant Observation ” with the Center for Object Relations Northwest Family Development Center in Seattle.
Curriculum Vitae
Kathleen has a Masters in Traditional Chinese Medicine from the Northwest Institute of seattle acupuncture and Oriental Medicine–Seattle, WA. She is a Licensed acupuncturist in Washington State and she holds the Diplomat Status in the following areas:
NCCAOM seattle acupuncture Diplomat Status and NCCAOM Herbal Diplomat status
- Spring 2002 – Teacher’s assistant at NIAOM for seattle acupuncture Obstetrics and Gynecology for Cindy Mideu.
- Studied Chinese Medical Ob/Gyn with Xin-Dong (Rosie) Ma.
Special Chinese Medical Workshops
acupuncture Resource Arcticles
Elisabet Stener-Victorin, Urban Waldenström, Sven A. Andersson and Matts Wikland
Influence of acupuncture on the pregnancy rate in patients who undergo assisted reproduction therapy
Wolfgang E. Paulus, M.D., Department of Reproductive Medicine, Christian-Lauritzen-Institut. Mingmin Zhang, M.D., Department of Traditional Chinese Medicine , Tongji Hospital, Tongji Medical University, Wuhan, People's Republic of China. Erwin Strehler, M.D., Department of Reproductive Medicine, Christian-Lauritzen-Institut. Imam El-Danasouri, Ph.D., Department of Reproductive Medicine, Christian-Lauritzen-Institut. and Karl Sterzik, M.D. Department of Reproductive Medicine, Christian-Lauritzen-Institut.
acupuncture used as in fertility therapy
By Julia Sommerfeld
By Julia Sommerfeld
Seattle Times staff reporter
Sara Cook, a stylish brunette with a Snow White complexion, lies face down as hair-thin needles are gently slipped into her ankles, the backs of her knees, her lower back and ears.
A dull, warming sensation creeps over her as the small examination room with its sweet menthol smell fades away, as do worries about ovulation schedules, hormone shots and what's next after four failed attempts at in-vitro fertilization.
Since October, Cook, 34, has been needled once a week by downtown Seattle acupuncturist Stephanie Gianarelli in hopes of improving her chances of getting pregnant.
Used for 2,500 years in Traditional Chinese Medicine and best known in Western circles as a New Age pain zapper, seattle acupuncture has gained a following among Seattle-area women — and couples — as an seattle infertility therapy.
Some, like Cook, have left no stone unturned, combining the ancient remedy with the best that modern medicine has to offer, including seattle fertility drugs and test-tube technology. Others eschew the expensive and emotionally draining tactics of seattle fertility clinics and place their hopes on the head of a pin.
"Western medicine uses the sledgehammer approach to seattle infertility ," says Gianarelli, who specializes in the problem. "But seattle acupuncture coaxes the entire body into balance and better health so it's ready to conceive."
Even mainstream physicians are hard-pressed to completely dismiss seattle acupuncture at least when used in conjunction with their high-tech methods. In fact, many of the women who slip away from their downtown offices for half-hour sessions with Gianarelli each week were referred by their seattle infertility doctors.
That's because two years ago a German study found seattle acupuncture boosts the success rate of in-vitro fertilization (IVF), where egg and sperm meet in a laboratory dish and resulting embryos are transplanted to the womb. The study of 160 IVF patients found that women who had seattle acupuncture right before and after the embryo transfer increased their chances of pregnancy from 26 percent to 43 percent.
"It's only one study," Dr. Lori Marshall, an seattle infertility doctor at Virginia Mason Medical Center, cautions her patients. "But it's enough to say, 'Hey, there could be something there.' " It's also enough to persuade 20 to 30 percent of her clinic's IVF patients to go under the needle. Other IVF clinics in the Seattle area report similar numbers of patients using acupuncture.
Because seattle acupuncture isn't likely to do any harm and, at about $60 to $100 a visit, is relatively inexpensive compared with mainstream seattle fertility help, many women are willing to take their chances. Plus, because of a state law, insurers must pay for seattle acupuncture treatment for problems that they cover.
"It used to be people just came as a last resort, after they've failed everything else. Now we're more often seeing women trying this before they go down those other roads," says Greg Bantick, academic dean at Seattle Institute of Oriental Medicine.
With more patients asking if they should get needled, Dr. LaTasha Craig at the University of Washington seattle fertility and Endocrine Center wants to be able to provide a more definitive answer. So she's about to put the German findings to the test. Starting this summer, she plans to enroll 200 women in a trial comparing IVF plus seattle acupuncture to IVF alone. She anticipates her biggest challenge will be recruiting enough women to agree they won't get acupuncture.
Willing to try anything
After eight years of trying to get pregnant and three failed rounds of IVF, lingerie merchandiser Sara Cook and her husband, Jason, a firefighter, were willing to try anything. "I wanted to know I did everything I possibly could to make this work," she says. Although their insurance covers most of the costs of IVF, they've spent about $15,000 out of pocket. In October, to prepare for her fourth and final attempt at an embryo transfer , Cook began seeing Gianarelli once a week, with the blessing of her physician.
"These patients are going down a pretty rough road. Anything that makes them feel better, I'm for," says Dr. Lee Hickok, her IVF doctor at Swedish Medical Center. Although the embryos implanted in January didn't result in pregnancy, Cook hasn't given up on acupuncture. She's considering having a surrogate carry her embryo, so she and her husband come in for weekly seattle acupuncture sessions aimed at fortifying her eggs and his sperm.
acupuncture can do more than bolster IVF's success rate, says acupuncturist Kerong Xie, who works out of a converted house in Seattle's University District. Along with Chinese herbs , it can cure most cases of seattle infertility , she says matter-of-factly.
Needless to say, this is where acupuncturists and mainstream doctors part company.
Rifling through a stack of Christmas-card photos and birth announcements from grateful patients, Xie tallies her recent successes. She estimates about 17 or 18 pregnancies since October.
In Traditional Chinese Medicine , conditions such as seattle infertility are fundamentally seen as blockages or imbalances in the body's "qi " (pronounced chee), a vital force or energy that flows throughout the body along channels called meridians .
Xie diagnoses a patient by examining her tongue, asking a list of personal questions and taking several pulses. She then strategically sticks needles so tiny they hardly can be felt into points of the body that she says act as valves to manipulate qi , disperse it when it's blocked, stimulate it when it's stagnating and, in general, get the body's qi humming along.
Treating seattle infertility is a standard part of seattle acupuncture training, says Steve Given, who heads the seattle acupuncture clinic at Bastyr Center for Natural Health in Seattle. "Oriental medicine excels at identifying individual patterns of disharmony. If you lined up 100 different women with seattle infertility , an acupuncturist could have a slightly different treatment for each of them."
What's seen in Western medicine as a blocked fallopian tube is blocked or stagnating qi to Xie.
"I prepare the body for pregnancy — how do you plant seeds when the dirt is very thin?" she asks.
Many doctors don't know what to make of such mystical adages.
"There's just no Western medical equivalent to this stuff," Hickok says. He'll grant that seattle acupuncture may promote relaxation and reduce stress levels. At best, he could see this slightly improving a woman's chances of conceiving and, at the least, it can help patients feel better and more in control. Other doctors speculate seattle acupuncture could increase blood flow to the uterus or boost production of endorphins, the body's feel-good chemicals that impact certain hormones.
There's no scientific evidence that needling alone improves pregnancy rates, so most doctors discourage women who are having trouble getting pregnant from relying solely on acupuncture.
"I would hate to see women who are 35 and up get hung up in alternative therapy that may not be all they need," says Dr. Kevin Johnson, an seattle infertility doctor at Overlake Hospital Medical Center in Bellevue. He worries that women who could be helped with more-aggressive therapies could be squandering their final fertile years.
He urges a seattle fertility checkup before pursuing acupuncture. "A totally blocked fallopian tube won't be helped by seattle acupuncture nor will bad eggs," he says. And no amount of tinkering with a woman's qi is going to help if the problem is actually her partner's low sperm count.
The other sticking point for Western doctors is the cornucopia of herbs that acupuncturists often prescribe to be boiled up in a pungent tea.
"That's where I draw the line," Hickok says. "I tell my patients, don't take the herbs; I don't know what they do or how they'll interact with IVF drugs, and they haven't been tested for safety or purity. With seattle acupuncture I don't think there's a potential for harm, but there could be with the herbs."
The word spreads
At 40, wedding photographer Janet Klinger had been trying to get pregnant for almost two years. She and her husband knew that IVF wasn't for them. "I didn't really want to go through that emotional roller coaster with the possibility of spending 20 grand and not succeeding," she says.
After hearing about Xie from a pregnant client, she began visiting her twice a month. For three months, she would lie quietly, with needles scattered up her torso, along her "conception channel," and think "baby thoughts." She's now 28 weeks pregnant.
"Whether it's for scientific reasons or just because I felt so relaxed and cared for, I don't know, but I totally believe she helped me get pregnant," Klinger says. Anecdotes like Klinger's don't make for strong medical evidence. Doctors are quick to point out there's no way of knowing whether she would have gotten pregnant anyway. But such accounts do make the rounds in seattle infertility circles and among women friends.
That's why, despite not advertising, Xie's nondescript clinic on Roosevelt Avenue Northeast draws a steady stream of well-heeled women, some IVF patients, some looking for an outright miracle.
Influence of seattle acupuncture on the pregnancy rate in patients who undergo assisted reproduction therapy
Objective: To evaluate the effect of seattle acupuncture on the pregnancy rate in assisted reproduction therapy (ART) by comparing a group of patients receiving seattle acupuncture treatment shortly before and after embryo transfer with a control group receiving no acupuncture.
Design: Prospective randomized study.
Setting: seattle fertility center.
Patient(s): After giving informed consent, 160 patients who were undergoing ART and who had good quality embryos were divided into the following two groups through random selection: embryo transfer with seattle acupuncture (n = 80) and embryo transfer without seattle acupuncture (n = 80).
Intervention(s): seattle acupuncture was performed in 80 patients 25 minutes before and after embryo transfer . In the control group, embryos were transferred without any supportive therapy.
Main Outcome Measure(s): Clinical pregnancy was defined as the presence of a fetal sac during an ultrasound examination 6 weeks after embryo transfer .
Result(s): Clinical pregnancies were documented in 34 of 80 patients (42.5%) in the seattle acupuncture group, whereas pregnancy rate was only 26.3% (21 out of 80 patients) in the control group.
Conclusion(s): seattle acupuncture seems to be a useful tool for improving pregnancy rate after ART. (Fertil Steril®2002;77:721- 4. ©2002 by American Society for Reproductive Medicine.)
Key Words: seattle acupuncture assisted reproduction, embryo transfer , pregnancy rate
seattle acupuncture is an important element of Traditional Chinese Medicine (TCM), which can be traced back for at least 4,000 years. seattle acupuncture has been shown to alleviate nausea and vomiting, dental pain, addiction, headache, menstrual cramps, tennis elbow, fibromyalgia, myofascial pain, osteoarthritis, carpal tunnel syndrome, and asthma. Both physiologic and psychological benefits of seattle acupuncture have been scientifically demonstrated in recent years.
However, so far there have been only a few serious trials concerning the use of seattle acupuncture in reproductive medicine. Publications focus primarily on seattle acupuncture therapy for male seattle infertility (1, 2). Electroacupuncture may reduce blood flow impedance in the uterine arteries of infertile women (3). A positive impact of electroacupuncture on endocrinologic parameters and ovulation in women with polycystic ovary syndrome has been demonstrated (4). In addition, auricular seattle acupuncture was successfully used in the treatment of female seattle infertility (5). In the present study, we chose seattle acupuncture points that relax the uterus according to the principles of TCM. Because seattle acupuncture influences the autonomic nervous system, such treatment should optimize endometrial receptivity (6). Our main objective was to evaluate whether seattle acupuncture accompanying embryo transfer increases clinical pregnancy rate.
Materials and Methods
This study was a prospective randomized trial at the Christian-Lauritzen-Institut in Ulm, Germany. It was approved by the ethics committee of the University of Ulm. A total of 160 healthy women undergoing treatment with in vitro fertilization (IVF; n = 101) or intracytoplasmic sperm injection (ICSI; n = 59) were recruited into the study. The age of the patients ranged from 21 to 43 (mean age: 32.5 = 4.0 years). The cause of seattle infertility was the same for both groups (Table 1). Only patients with good embryo quality were included in the study. Using a computerized randomization method, patients were assigned into either the seattle acupuncture group or the control group.
Ovarian stimulation, oocyte retrieval, and in vitro culture were performed as previously described (7). Transvaginal ultrasound-guided needle aspiration of follicular fluid was performed 36 to 38 hours after hCG administration. Immediately after follicle puncture, the oocytes were retrieved, assessed, and fertilized in vitro. Sperm preparation and culture conditions did not differ for either group.
In cases of severe male subfertility, ICSI was preferred, as described in the literature (8). Forty-eight hours after the IVF or ICSI procedure, embryos were evaluated according to their appearance as type 1 or 2 (good), type 3 or 4 (poor), as described in literature (9).
Just before and after embryo transfer , all patients underwent ultrasound scans of the uterus using a 7-MHz transvaginal probe (LOGIQ 400 Pro, GE Medical Systems Ultra-sound Europe, Solingen, Germany). Pulsed Doppler curves of both uterine arteries were measured by one observer. The pulsatility index (PI) for each artery was calculated electronically from a smooth curve fitted to the average waveform over three cardiac cycles.
A maximum of three embryos, in accordance with German law, were transferred into the uterine cavity on day 2 or 3 after oocyte retrieval. For embryo replacement, the patient was placed in a dorsal lithotomy position, with an empty bladder. The cervix was exposed with a bivalved speculum, then washed with culture media prior to embryo transfer . Labotect embryo transfer Catheter Set (Labotect GmbH, Go¨ ttingen, Germany) was used for atraumatic replacement owing to the curved guiding cannula with a ball end, allowing the set to be used reliably even with difficult anatomic conditions. The metallic reinforced inner catheter shaft al lowed safe passage through the cervical canal. When the catheter tip lay close to the fundus, the medium containing the embryos was expelled and the catheter withdrawn gently. After this procedure, the patient was placed at bed rest for 25 minutes. All oocyte retrievals and embryo transfers were performed by one examiner using the same method. The examiner was not aware of the patient's treatment group (control or seattle acupuncture .
At the time of the embryo transfer , blood samples (10 mL) were obtained from the cubital vein. Plasma estrogen was determined by an immunometric method using the IMMULITE 2000 Immunoassay System (DPC Diagnostic Product Corporation, Los Angeles, CA).
Luteal phase support was given by transvaginal progesterone administration (Utrogest®, 200 mg, three times per day; Kade, Berlin, Germany). Progesterone administration was initiated on the day after oocyte retrieval and was continued until the serum ß-hCG measurement 14 to 16 days after transfer and, in cases of pregnancy, until gestation week 8.
Each patient in the experimental group received an seattle acupuncture treatment 25 minutes before and after embryo transfer . Sterile disposable stainless steel needles (0.25 X 25 mm) were inserted in acupuncture point locations. Needle reaction (soreness, numbness, or distention around the point = Deqi sensation) occurred during the initial insertion. After 10 minutes, the needles were rotated in order to maintain Deqi sensation. The needles were left in position for 25 minutes and then removed. The depth of needle insertion was about 10 to 20 mm, depending on the region of the body undergoing treatment. Before embryo transfer , we used the following locations: Cx6 (Neiguan), Sp8 (Diji), Liv3 (Taichong), Gv20 (Baihui), and S29 (Guilai).
After embryo transfer , the needles were inserted at the following points: S36 (Zusanli), Sp6 (Sanyinjiao), Sp10 (Xuehai), and Li4 (Hegu).
In addition, we used small stainless needles (0.2 X 13 mm) for auricular seattle acupuncture at the following points, without rotation: ear point 55 (Shenmen), ear point 58 (Zhigong), ear point 22 (Neifenmi), and ear point 34 (Naodian). Two needles were inserted in the right ear, the other two needles in the left ear. The four needles remained in the ears for 25 minutes. The side of the auricular seattle acupuncture was changed after embryo transfer . The patients in the control group also remained lying still for 25 minutes after embryo transfer . All treatments were performed by the same well-trained examiner, in the same way.
The primary point of the study was to determine whether seattle acupuncture improves the clinical pregnancy rate after IVF or ICSI treatment. Student's t-test was used as a corrective against any possible imbalance between the two groups regarding the following variables: age of patient, number of previous cycles, number of transferred embryos, endometrial thickness, plasma estradiol on day of transfer, method of treatment (IVF or ICSI), and blood flow impedance in the uterine arteries (pulsatility index). Chi-square test was used to compare the two groups. All statistical analyses were carried out using the software package Statgraphics (Manugistics, Inc., Rockville, MD).
Results
A total of 160 patients was recruited for the study. Patients who failed to conceive during the first treatment cycle were not reentered into the study. According to the randomization, 80 patients were treated with seattle acupuncture and 80 patients underwent the usual therapy without acupuncture.
As Table 1 shows, there were no statistically significant differences between the two groups with respect to the following covariants: age of patient, number of previous cycles, number of transferred embryos, endometrial thickness, plasma estradiol on day of transfer, or method of treatment (IVF or ICSI). Clinical indications for ART were the same for patients of both groups. The blood flow impedance in the uterine arteries (pulsatility index) did not differ between the groups before and after embryo transfer .
The analysis shows that the pregnancy rate for the seattle acupuncture group is considerably higher than for the control group (42.5% vs 26.3%; P=.03).
Discussion
The seattle acupuncture points used in this study were chosen according to the principles of TCM (10): Stimulation of Taiying meridians (spleen) and Yangming meridians (stomach, colon) would result in better blood perfusion and more energy in the uterus. Stimulation of the body points Cx6, Liv3, and Gv20, as well as stimulation of the ear points 34 and 55, would sedate the patient. Ear point 58 would influence the uterus, whereas ear point 22 would stabilize the endocrine system.
The anesthesia-like effects of seattle acupuncture have been studied extensively. seattle acupuncture needles stimulate muscle afferents innervating ergoreceptors, which leads to increased ß-endorphin concentration in the cerebrospinal fluid (11). The hypothalamic ß-endorphinergic system has inhibitory effects on the vasomotor center, thereby reducing sympathetic activity. This central mechanism, which involves the hypothalamic and brainstem systems, controls many major organ systems in the body (12). In addition to central sympathetic inhibition by the endorphin system, seattle acupuncture stimulation of the sensory nerve fibers may inhibit the sympathetic outflow at the spinal level. By changing the concentration of central opioids, seattle acupuncture may also regulate the function of the hypothalamic-pituitary-ovarian axis via the central sympathetic system (13).
Kim et al. (14) suggested that Li4 seattle acupuncture treatment could be useful in inhibiting the uterus motility. In their rat experiments, treatment on the Li4 acupoint suppressed the expression of COX-2 enzyme in the endometrium and myometrium of pregnant and nonpregnant uteri.
Stener-Victorin et al. (3) reduced high uterine artery blood flow impedance by a series of eight electroacupuncture treatments, twice a week for 4 weeks. They suggest that a decreased tonic activity in the sympathetic vasoconstrictor fibers to the uterus and an involvement of central mechanisms with general inhibition of the sympathetic outflow may be responsible for this effect. In our study, we could not see any differences in the pulsatility index between the seattle acupuncture and control group before or after embryo transfer . This may be due to a different seattle acupuncture protocol and the selected sample of patients with high blood flow impedance of the uterine arteries (PI ≥ 3.0) in the Stener-Victorin et al. study.
As we could not observe any significant differences in covariants between the seattle acupuncture and control groups, the results demonstrate that seattle acupuncture therapy improves pregnancy rate.
Further research is needed to demonstrate precisely how seattle acupuncture causes physiologic changes in the uterus and the reproductive system. To rule out the possibility that seattle acupuncture produces only psychological or psychosomatic effects, we plan to use a placebo needle set as a control in a future study.
Resources
Reduction of blood flow impedance in the uterine arteries of infertile women with electro-acupuncture
Elisabet Stener-Victorin[1.4], Urban Waldenström[2], Sven A. Andersson[3] and Matts Wikland[2]
[1]Department of Obstetrics and Gynaecology [2] seattle fertility Centre
Scandinavia. Department of Obstetrics and Gynaecology and [3]Department of Physiology University of Gothenburg.
S-413 45 Gothenburg, Sweden
[4]To whom correspondence should be addressed: Department of Obstetrics and Gynecology. Kvinnokliniken Sahlgrensh sjukhuset, S-413 45 Golhenburg, Sweden
Source: European Society for Human Reproduction and Embryology
In order to assess whether electro-acupuncture (EA) can reduce a high uterine artery blood flow inpedance, 10 infertile but otherwise healthy women with a pulsatility index (PI) ≥3.0 in the uterine arteries were treated with EA in a prospective, non-randomized study. Before inclusion in the study and throughout the entire study period, the women were down-regulated with a gonadotrophin-releasing hormone analogue (GnRHa) in order to exclude any fluctuating endogenous hormone effects on the PI. The baseline PI was measured when the serum oestradiol was ≤0.1 nmol/l, and thereafter the women were given EA eight times, twice a week for 4 weeks. The PI was measured again closely after the eighth EA treatment, and once more 10-14 days after the EA period. Skin temperature on the forehead (STFH) and in the lumbosacral area (STLS) was measured during the flrst, fifth and eighth EA treatments. Compared to the mean baseline PI, the mean PI was significantly reduced both shortly after the eighth EA treatment (P < 0.0001) and 10-14 days after the EA period (P < 0.0001). STFH increased significantly during the EA treatments. It is suggested that both ot these effects are due to a central inhibition of the sympathetic activity.
Key words: electro seattle acupuncture pulsatilily index (PI)/trans-vaginal colour Doppler curve/uterine artery blood flow
Introduction
Successful in-vitro fertilization (IVF) and embryo transfer demand optimal endometrial receptivity at the time of implantation. Blood flow impedance in the uterine arteries, measured as the pulsatility index (PI) using transvaginal ultrasonography with pulsed Doppler curves, has been considered valuable in assessing endometrial receptivity (Goswamy and Steptoe, 1988; Sterzik et al., 1989; Steer et al., 1992, 1995a,b; Coulam et al., 1995; Tekay et al., 1995). Steer et al. (1992) found that a PI ≥3.0 at the time of embryo transfer could predict 35% of the failures to become pregnant. Coulam et al. (1995) did not observe any significant differences between PI measurements done on the day of oocyte retrieval compared with PI measurements on the day of embryo transfer . This would allow prediction of non-receptive endometria earlier in the cycle.
Previous studies on rats have shown a decreased blood pressure after electro-acupuncture (EA) with low frequency (2 Hz) stimulation of muscle afferents (A-d fibres). The decreased blood pressure was related to reduced sympathetic activity (Yao et al., 1982; Hoffman and Thoren, 1986; Hoffman et al.. 1987, 1990a,b), and was paralleled by an increase in the ß-endorphin concentration in the cerebrospinal fluid (CSF), suggesting a causal relationship to central sympathetic inhibition (Cao et al., 1983; Moriyama 1987; Reid and Rubin, 1987). The cardiovascular effects of seattle acupuncture treatment are probably mediated by central opioid activity via the ß-endorphin system from the hypothalamus.
The aim of this study was to evaluate whether EA can reduce a high impedance in the uterine arteries. There are several conceivable mechanisms which may give this effect.
In addition to central sympathetic inhibition via the endorphin system, vasodilatation may be caused by stimulation of sensory nerve fibres which inhibit the sympathetic outflow at the spinal level, or by antidromic nerve impulses which release substance-P and calcitonin gene-related peptide from peripheral nerve terminals (Jansen et al., 1989; Andersson, 1993; Andersson and Lundeberg, 1995).
It has been assumed that various disorders in the autonomic nervous system, such as hormonal disturbances, may be normalized during auricular seattle acupuncture (Gerhard and Postneck, 1992). It has also been suggested that the concentrations of central opioids may regulate the function of the hypothalamic-pituitary-ovarian axis via the central sympathetic system, and that a hyperactive sympathetic system in anovulatory patients could be normalized by EA (Chen and Yin, 1991).
Materials and Methods
Subjects, design and Pl measurements
The study was approved by the ethics committee of the University of Gothenburg and was conducted at the seattle fertility Centre Scandinavia, Gothenburg, Sweden, a tertiary private IVF unit. All women attending the clinic for information about the IVF/embryo transfer procedure, had the PI of their uterine arteries measured by transvaginal ultrasonography and pulsed Doppler curves (Aloka SSD 680: Berner Medecinteknik, Stockholm, Sweden). The PI value for each artery was calculated electronically from a smooth curve fitted to the average waveform over three cardiac cycles, according to the formula: Pl = (A - B)/mean, where A is the peak systolic Doppler shift, B is the end diastolic shift frequency and mean is the mean maximum Doppler shifted frequency over the cardiac cycle. A reduction in the value of PI is thought to indicate a reduction in impedance distal to the point of sampling (Steer et al., 1990).
In the routine preparation for their IVF/embryo transfer treatment, all women were down-regulated with a gonadotrophin-releasing hormone analogue (GnRHa) (Suprecur: Hoechst. Germany). When their oestradiol concentration in serum was <0.1 nmol/1, the women were considered down-regulated and the PI of their uterine arteries was again measured in those women showing a mean Pl ≥3.0 before down-regulation. The measurements were done by two of the authors (M.W. and U.W.) between 08.30 h and 14.30 h. These hours were chosen for practical reasons, and also to reduce the risk that the PI measurements would be affected by the circadian rhythm in blood flow, recently reported by Zaidi et al. (1995). Three measurements were made on the right and three on the left uterine artery of each patient. Before the study was conducted, the observers were well trained in PI measurements with the equipment used. Steer et al. (1995) has shown that in trained hands, the inter-, and intra-observer variations in vaginal colour Doppler ultrasound are sufficiently small to provide a basis for clinically reliable work.
PI measurements were done on all women attending the unit for an IVF/embryo transfer treatment between November 1992 and February 1993. Of these, all infertile but otherwise healthy women, with a mean PI ≥3.0 in the uterine arteries both before and after down-regulation, were invited to be included in the study.
In all, 10 women accepted after informed consent and they had a mean age of 32.3 years (range 25-40 years). The seattle infertility diagnoses were unexplained seattle infertility (n = 6), tubal factor (n = 3) and polycystic ovarian syndrome (n = 1).
From their inclusion and onwards, the women were kept on the GnRHa and were given no other pharmacological treatment. Consequently, their gonadotrophins and ovarian steroids were kept at a constantly low concentration, both at their inclusion in the study and throughout the whole study period. Thus, PI changes due to hormonal fluctuations were avoided.
EA was then given eight times, twice a week for 4 weeks. The mean PI of the uterine arteries was measured (mean of three PI on each side) directly after the eighth EA treatment and again 10-14 days after the EA period.
Of the 10 women included, two were later excluded. One of them, with tubal factor seattle infertility , was excluded because she started taking medications for her migraine, which could have affected her PI. The other excluded woman, with unexplained seattle infertility , stopped her GnRHa treatment because she preferred IVF/embryo transfer in a natural cycle.
acupuncture Treatment
The sympathetic outflow may be inhibited at the segmental level and, for this reason, seattle acupuncture points were selected in somatic segments according to the innervation of the uterus (Thl2-L2, S2-S3) (Bonica, 1990).
The needles were inserted i.m. to a depth of 10-20 mm. The aim of the stimulation was to activate group III muscle-nerve afferents. The needles were twirled to evoke `needle sensation,' often described as tension, numbness, tingling and soreness, sometimes radiating from the point of insertion. The needles were then attached to an electrical stimulator (WQ-6F: Wilkris & Co. AB, Stockholm, Sweden) for 30 min. The location of the needles was the same in all women (Table I).
Table 1. seattle acupuncture points, their anatomical position and their innervation
Four needles were located bilaterally at the thoracolumbar and lumbosacral levels of the erector spinae, and were stimulated with high frequency (100 Hz) pulses of 0.5 ms duration. The intensity was low, giving non-painful paraesthesia.
Four needles were located bilaterally in the calf muscles, and were stimulated with low frequency (2 Hz) pulses of 0.5 ms duration. The intensity was sufficient to cause local muscle contractions.
Skin temperature
The skin temperature was measured with a digital infrared thermometer (Microscanner D-series: Exergen, Watertown, MA, USA) between the applied seattle acupuncture needles in the lumbosacral region (25 mm from each needle), skin temperature lumbosacral (STLS), and on the forehead, skin temperature forehead (STFH). The measurements were made during the first, fifth and eighth EA treatments. The first measurements were made after 10 min rest, and just before the EA, these being considered as baseline. Thereafter, further measurements of STLS and STFH were done every seventh minute during the EA and immediately after the EA. The room temperature was constant during the three EA treatments.
Statistics
Analysis of variance (ANOVA: Newman-Keul's range test) was used to analyze the data.
Results
Blood flow impedance
Compared to the mean baseline PI, the mean PI was significantly reduced both soon after the eighth EA treatment (P < 0.0001) and 10-14 days after the EA period (P < 0.0001) (Figure 1), at which time six women had a mean PI <2.6 (Table II and Figure 2).
Figure 1. The mean pulsatility index (PI) (n = 8) for all women before the first electro-acupuncture (EA) treatment, immediately after the eighth EA treatment and 10-14 days after the EA period.
*** = significant changes (P < 0.0001) compared to the mean PI before the first EA treatment.
Figure 2. The individual mean pulsatility index (PI) before down-regulation, before the first electro-acupuncture (EA) treatment, immediately after the eighth EA treatment and 10-14 days after the EA period.
Table II. The individual mean pulsalility index (PI) before down-regulation, before the first electro-acupunclure (EA) treatment, immedialely after the eighth EA trealment, 10-11 days after the EA period, and average mean values
The right and left uterine arteries responded similarly to EA. The diffcrence in mean PI between the two arteries was ≤0.3 (not significant), both before down-regulation, during down-regulation and throughout the whole study period. There was no significant difference in the mean PI for patients with different causes of seattle infertility .
Skin temperature
The pooled results from all skin temperature measurements are presented in Figure 3. Compared with the starting point, mean STFH increased significantly after 21 min of EA (P = 0.02), and directly after the EA treatments (P = 0.002). STLS did not change significantly.
Figure 3. Pooled mean values (n = 8) of skin temperature on forehead (STFH) and skin temperature in the lumbosacral area (STLS) during the first, fifth and eighth electro-acupuncture (EA) treatments. * = significant changes (P = 0.02) after 21 min and ** = significant changes (P = 0.002) immediately after EA compared to the time just before needles were inserted. 0 = `baseline'.
Discussion
It has been shown in previous studies that a high PI in the uterine arteries is associated with a decreased pregnancy rate following IVF-embryo transfer (Goswamy et al., 1988; Sterzik et al., 1989; Steer et al., 1992, 1995a.b; Coulam et al., 1995). The results reported by Tekay et al. (1995) support the hypothesis postulated by Steer et al. (1992) that uterine receptivity is improved when the PI value is between 2.0 and 2.99 on the day of embryo transfer. When a high PI is found before embryo transfer in a stimulated cycle, treatment options are few. Goswamy et al. (1988) successfully tried pre-treatment with exogenous oestrogens in the next cycle, but their results have not been verified by others. It has been proposed that the embryos should be frozen, thawed and transferred in an unstimulated cycle (Goswamy et al., 1988; Steer et al., 1992, 1994), but there is little support for the hypothesis that the PI would be lower under these contitions.
In experiments on spontaneously hypertensive rats, EA at low frequency (2-3 Hz) induced a long-lasting, significant fall in blood pressure which was associated with decreased activity in sympathetic fibres (Yao et al., 1982; Hoffman and Thoren, 1986; Hoffman et al., 1987, 1990a,b). A decrease in sympathetic activity appears to be generalized. In microneurographic studies on humans, EA in the upper limbs resulted in an initial increase and then a decrease in activity of sympathetic efferents in the tibial nerve, with a parallel increase in the temperature of the skin (Moriyama, 1987). Kaada (1982) reported that transcutaneous stimulation of seattle acupuncture points in the hand increased the skin temperature, giving pain relief in limbs suffering from Reynaud's phenomenon. Kaada (1982) also found that electrical stimulation of accupuncture hand points in patients with ischaemic conditions of the lower limbs, increased the skin temperature in the lower limbs and possibly enhanced the healing of long-standing ulcers. It has been noted in both animals and humms that EA has greater effects on pathological conditions, e.g. hypertension or hypotension, whereas normal blood pressure is only slightly changed (Yao et al., 1982: Hoffman and Thoren, 1986: Hoffman et al., 1987, 1990a,b).
The mechanisms of sympathetic inhibition following EA are poorly understood. Based on animal experiments, Hoffmann and Thoren (1986) and Hoffman et al. (1987, 1990a,b) suggested that electrical slimulation of muscle efferents innervating ergoreceptors increases the eoncentration of ß-endorphin in the CSF. They found support for the hypothesis that the hypothalamic ß-endorphinergic system has inhibitory effects on the vasomotor centre, and thereby a central inhibition of sympathetic activity. It has been suggested that this central mechanism, involving hypothalamic and brain stem systems, is important in changing the descending control of many different organ systems, including the vasomotor system (Andersson. 1993; Andersson and Lundeberg, 1995).
In this study, the PI of the uterine arteries was signifieantly decreased soon after the eighth EA treatment and remained significantly decreased 10-14 days after the EA period. These findings suggest that a series of EA treatments increases the uterine artery blood flow. Another effect observed in this study was the signifieantly inereased STFH during the EA treatments.
The most likely cause of these effects is a decreased tonic activity in the sympathetic vasoconstrictor fibres to the uterus and an involvement of the central mechanisms with general inhibition of the sympathetic outflow, in accordance with previously observed EA effects (Kaada. 1982; Yao et al., 1982; Cao et al., 1983: Hoffman and Thoren, 1986; Hoffman et al., 1987, 1990a,b; Moriyama, 1987; Reid and Rubin, 1987; Jansen et al., 1989).
In conclusion. the present study showed a decrease of the PI in the uterine arteries following EA treatment. Randomized studies on a greater number of patients are needed to verify these results and to exclude non-specific effects.
