19 The Treatment of Male Infertility with TCM This chapter indicates the significance of male infertility in the context of fertility treatment. On the basis of gathered experience, it offers an overview of the substantial possibilities and conditions for an effective and practicable therapy with TCM. It is intended to stimulate practitioners to devote themselves to this task. In the United States, the Center for Disease Control reported a continuing drop in the birth rate to 13.9 per 1000 persons in 2002, down from 14.1 per 1000 in 2001 and down a full 17% from the recent peak in 1990 (16.7 per 1000).3 In Germany, the birth rate has dropped by almost half in the postwar period.24 In the year 2005, it dropped to a historic low. According to the Federal Institute for Population and Development, this trend will continue. This trend will continue. The media took up the subject extensively in the spring of 2006. The aging and ultimately dying nation becomes a threatening vision. The collapse of government retirement programs appears inevitable. The main reason under discussion for the falling birth rate is the conscious renunciation of childbearing, whether due to selfish motivations to advance one’s professional career and be able to afford anything for oneself or due to social insecurity or even poverty and societal hostility towards children. Nevertheless, childlessness is not always the result of personal life planning. We often overlook that fact that, according to the 2002 National Survey of Family Growth in the United States, 7% of married couples in which the woman was of reproductive age (2.1 million couples) reported that they had not used contraception for 12 months and the woman had not become pregnant. For the affected women and men, this is a difficult fate, but the effects on society as a whole are considerable as well. There is no lobby for childless people because some of them still have hope, while the others have given up long ago. The number of centers for reproductive medicine that have sprung up does not necessarily guarantee that those affected by this problem receive the information and care they need. Strict legal restrictions in some countries furthermore compel more and more couples to seek help abroad, as used to be the case with abortions in the past. Currently, patient care for abortions is considerably better than for fertility treatment. In Germany, for example, many couples can no longer afford artificial fertilization since the national health insurance drastically limited payment in 2004. As a result, co-payments have been halved and limited to three attempts as well as by age. As a result, in 2005, roughly 20,000 children were born by means of artificial insemination.30 This may have been worthwhile for the insurance, but is a setback for the affected couples and for society. The dilemma of involuntary childlessness could hardly be greater. The causes of infertility are largely unknown. Related research is urgently needed. Even though word is gradually getting out that at least half of this problem, which is shared by both partners, is caused by the man, treatment still tends to be focused only on the woman. Fully developed and gentle treatment concepts are largely unknown. In this context, TCM, which has been dealing with infertility treatment already since the 11th century BCE, can make an important contribution. Especially effective are the possibilities in the treatment of male infertility, for which biomedicine knows few options. Male fertility depends both on good sperm production in the testicles and on an unobstructed transport through the seminal tract until the sperm reaches and fertilizes the ovum. Spermiogenesis takes about 70–90 days. The ideal temperature for the testicles is 35 °C (95 °F). Sperm quality has dropped distinctly in the last few years for men in Europe, according to the results of a study from Oldenburg under the auspices of the WWF. 14 Causes of infertility are primarily related to sperm production, but also to transport. Traditional causes are infections, especially mumps, undescended testicles, sexually transmitted diseases, diabetes mellitus, injury, surgery, and varicose veins in the testes (varicocele testis). Hormonal disturbances and genetic causes can impact fertility as well. Also under discussion is the topic “lifestyle” (i. e., unhealthy diet, smoking, alcohol and drug abuse, medications such as antihistamines, stress) and environmental factors (Figs. 19.1). While research has shown the damaging effects of smoking, the harm done by environmental factors remains quite vague. Fig. 19.1 Text on a cigarette pack. © European Community, Audiovisual Library of the European Commission. Here, we want to emphasize varicose veins in the testes and environmental factors in particular because they appear to be highly relevant but continue to be overlooked all too frequently. According to research by Tauber and Pfeiffer,27 41% of young adult men in Germany between the ages of 12 and 16 have a varicocele. Worldwide, this condition affects one-fifth of all men. Varicoceles are found in almost every second man unable to reproduce, with the large majority in the left testis. Varicose veins can affect circulation in the gonads and cause overheating, resulting in damage to the sperm. In the context of environmental factors, placticizers, ozone,22 heavy metals, and electromagnetic radiation, as well as hormones in the water and food are under discussion. Thus, estrogen has occasionally been found in drinking water.29 Still largely unknown are the effects of ultra-fine dusts, so-called nanoparticles, which have a toxic effect, overcome all physical barriers, and can influence the entire body. A very common source for emissions of heavy metals, ozone, volatile organic compounds, organozinc compounds with hormonal effects, and nanoparticles are laser printers and copy machines.26 Still unpublished experiments with toner on human lung cells by the Institute of Indoor and Environmental Toxicology at Giessen University have shown clear damaging effects.11 Toner-induced inflammatory processes also showed elevated TNF-alpha levels.25 A series of research by the Chicago gynecologist Alan Beer7 detected this cytokine in over 70% of examined women who had previously undergone three failed attempts at treatment with in vitro fertilization. After lowering the TNF-alpha level with medication, 78% of these women became pregnant. In one female fertility patient who constantly suffered from unexplained irritations and inflammations in the respiratory tract, the author detected by means of immunotolerance testing that she was reacting to the toner of her privately used laser printer with an 800-fold increase in her TNF-alpha level. The TNF-alpha information center (TIZ) reports online on several studies that demonstrate the link between elevated TNF-alpha levels and male infertility.28 The above may show how complex and unstudied but nevertheless potent environmental factors can be. Reproductive toxicology23 is surely a field of science with a future*, but we must also demand that naturopathy pay more attention to these changes, both in regards to diagnosis and treatment. The above-mentioned causes affect especially sperm production and the sperm cells themselves. In addition, disturbed transfer as well as antibody formation can be involved in both men and women. A root problem consists of overheating in the testicles, regardless of whether it is caused by a varicocele, overly tight clothing, excessive use of a sauna, bicycling, or inflammations. Lastly, the biological clock is ticking for men as well who also decide at a more and more advanced age that they want to become fathers (see Figs. 19.3). Male fertility remains constant up to age 35, but then drops until age 40 to about 40%, as US researchers report.9 Late paternity also means an increased risk of miscarriage and congenital defects for the child (for example dwarfism30). In addition to questioning and palpation, andrological examinations for infertility include testing an ejaculate sample, which is normally done by microscope or raster electron microscope (REM). There are also simple self-tests that might be helpful for orientation but cannot replace a medical examination by a specialist. Infertility is the inability to fertilize an egg; sterility is the inability to produce sperm cells. The basic parameters of a spermiogram are: According to WHO criteria, normal sperm findings range in volume from 2–6 mL with a sperm density of 20–120 million/mL. The percentage of targeted motile sperm should initially be > 50%. The waiting period (3–5 days) before a spermiogram must be observed, but should not be too long because this would affect motility in particular. Per ejaculate, there should be at least 40 million sperm cells to allow us to speak of a normal finding (Figs. 19.2). Fig. 19.2 Sperm: normal findings in spermiogram. The main diagnoses in pathological spermiograms are: In light of many millions of sperm cells, we should evaluate threshold values and percentage values with care. Even men with very poor values now and again succeed in becoming fathers, but it is simply a fact that the chances are lower. In addition to differentiating sperm defects, we can look at the following factors for relevant diagnoses: ___________ *Further information is available on www.nanocontrol.de/english.html A comparative, somewhat mechanistic consideration of male and female anatomy already suggests that it must be far easier to treat male fertility problems. In addition to comprehensive questioning and tongue and pulse diagnosis within the framework of a TCM medical history, we recommend recourse to biomedical findings under all circumstances. An up-to-date spermiogram is required, if necessary with raster electron microscopy to differentiate malformations. This should be checked after several weeks. Spermiograms should always be done by the same specialist to ensure their comparability. It should be determined whether a varicocele is present. Besides checking for the above-mentioned risks, the medical history should deal in particular detail with the patient’s lifestyle. Questions on diet, stress, sports, sex life, clothing, smoking, alcohol, medications, and exposure to chemicals or fine dust are also important for concurrent behavioral recommendations. A spermiogram can also be translated directly into a TCM diagnosis. In simplified terms, we can say that the sperm itself and its motility are associated with yang, while seminal fluid, sperm count, and morphology are associated with yin, or in the latter case also with jing. Exact differentiations and corresponding formulas have been introduced by Clavey5,6 in particular and are found in Liang.16 In the diagnosis of fertility problems, the kidney as the root of life and storehouse of essence lies at the center of our therapeutic interest. The kidney determines a person’s ability to reproduce. Diagnosis generally does not pose any particular problems and provides a clear approach for therapy. As the mirror image of our Western lifestyle, we find vacuity patterns and repletion patterns. Vacuity patterns, especially weakness of kidney yang and weakness of blood, tend to be the result of a consuming lifestyle and great professional demands, especially at an advanced age. Problems with the libido are not always only caused by a lack of yang, but are in men, as well as in women, frequently related to a liver qi stagnation, due to stress in one’s professional and/or personal life, not the least of which can be reproductive stress. In general, repletion patters are related primarily to damp-heat and to qi stagnation and blood stasis. We often find a varicocele. Due to the lack of research, general statements on the relevance of these TCM diagnoses are difficult. Thus, we are limited to personal therapeutic experiences, which in the present case are based in particular on patients who had already undergone measures of artificial insemination. The options of biomedicine are in essence limited to the treatment of infections and the surgical removal of varicoceles, as well as the retrieval of sperm from the testicles when the seminal tract is obstructed. In cases with impaired findings in the spermiogram, TCM under all circumstances recommends treatment. Hereby, Chinese medicinal therapy offers the most comprehensive options and should form the focus.* Nevertheless, acupuncture and moxibustion also offer valuable assistance, especially with regard to sperm motility. There is no doubt that we can also achieve positive results by means of qi gong, tui na, and Chinese dietetics (see Chapters 9, 10, and 13). ___________ * Below, we only describe formulas that are not found in Bensky.2 The following medicinals can be used in the treatment of male infertility: The following two formulas give an overview of the application of suitable medicinals for the treatment of male infertility. Rx. Bu Shen Yi Jing Fang (Supplement the Kidneys Benefit the Jing Formula)17: Each in high dosages, with a daily dose of 12–15 g. Modifications for Insufficiency of Kidney Yin and Heat: Bei Tu Tang*: Additions and Modifications This formula was created for all “male problems,” such as impotence, spermatorrhea, bloody semen, low liquefaction, or chronic prostatitis. Handle it flexibly in accordance with the particular diagnosis. In heat patterns, for example, leave out tu si zi, and in yang insufficiency leave out huang bai; for varicocele, on the other hand, add blood-moving medicinals. ___________ * According to Clavey,5,6 after Xu Fusong. Designed by Xu Fusong, Journal of Chinese Medicine, 1996: 9. Vol. 37, p. 532. Mazin Al Khafaji1 lists several studies on the efficacy of acupuncture in male infertility. Already in 1984, a German study of 28 men found a statistically relevant improvement of sperm quality after only 10 treatments in 3 weeks. A Brazilian investigation of 19 patients concluded that two treatments a week with acupuncture and moxibustion over 10 weeks resulted in a significant increase of normal findings. A study from Tel-Aviv examined 20 men with azoospermia and severe OAT syndrome. It found a clear increase in sperm count in two-thirds of the men with azoospermia, especially in men with inflammations in the genital tract. Lewis15 points to a study by Shanghai University of TCM on electroacupuncture on SP-6 (san yin jiao), CV-4 (guan yuan), and CV-12 (zhong wan). In addition to an improvement in symptoms and sperm in all parameters, the researchers found a normalization of hormone values, especially estrogen (57.1 %) and testosterone (65.1 %). Especially when treating insufficiency of kidney yang, moxa therapy is indicated. To complement treatment, we can also use ear acupuncture, for example on the points for the testicles, endocrinium, shen men, the antiaggression point, or also specifically to stop smoking. For the various disease patterns of male infertility, treatment with a combination of medicinal therapy and acupuncture and moxibustion can occasionally be suitable. Experience shows, however, that the use of Chinese medicinal therapy alone already offers excellent treatment results. We have dispensed here with presenting any typical symptoms. For this information, the reader should refer to the standard texts by Maciocia18 and the advanced literature, but also to the case studies below and other contributions in this book. Rx. Zuo Gui Wan (Left-restoring [Kidney Yin] Pill Rx. Yang Jing Zhong Zi Fang (Essence-nourishing Seed-planting formula): Rx. You Gui Wan (Right-restoring [Life Gate] Pill)* Rx. Wu Zi Yan Zong Wan (Five Seeds Pills for Abundant Descendants)19 CV-4 (guan yuan), CV-6 (qi hai), GV-4 (ming men), BL-23 (shen shu), ST-36 (zu san li), SI-3 (hou xi) plus BL-62 (shen mai): to activate the du mai. GV-4, BL-23 ___________ * Also known as Right (Kidney)-restoring Pill. Rx. Long Dan Xie Gan Tang (Gentian Liver-draining Decoction) CV-4 (guan yuan), LR-8 (qu quan), SP-6 (san yin jiao), SP-9 (yin ling quan), LI-11 (qu chi), BL-40 (wei zhong), KI-7 (fu liu) Rx. Xiao Yao San (Free Wanderer Powder) Yin tang, LR-1 (da dun), LR-3 (tai chong), GB-34 (yang ling quan), SP-6 (san yin jiao) Rx. Xue Fu Zhu Yu Tang (House of Blood Stasisexpelling Decoction) SP-10 (xue hai), LR-8 (qu quan), ST-29 (gui lai), SP-6 (san yin jiao), ST-29 (gui lai), SP-4 (gong sun) plus PC-6 (nei guan): to activate the chong mai Rx. Gui Zhi Fu Ling Wan (Cinnamon Twig and Poria Pill) Lewis points to a Japanese study that found that after 3 months of taking this formula, the varicocele disappeared in 80% of cases, the sperm count improved in over 70% of cases, and sperm motility in over 60%.15 Supplement yin and blood and support essence, for example with: Support yang and qi, for example with: Move blood, for example with: Move and disinhibit blood, for example with: Rx. Tong Jing Jian (Channel-freeing Brew)5: The presentation of the following typical cases is meant to indicate particularly the possibilities for a successful treatment. A detailed description of each treatment is beyond the scope of this chapter. Police officer, age 37, 196 cm, 107 kg, infertility for 3 years, reduced sperm density (0–1% normal sperm), varicocele on the left, seven times negative ICSI (intracytoplasmatic sperm injection). Tendency to sweating, nightly attacks of ravenous hunger, great thirst, severe distention, malodorous soft stools, bleeding hemorrhoids. Damp-heat, liver qi stagnation, weakness in the center. Eliminate damp-heat, disperse the stagnation, strengthen the center and kidney with Chinese medicinal therapy and acupuncture. Couple therapy. Natural pregnancy after 3 months, birth of a healthy son. Senior executive, age 41, 184 cm, 70 kg, gaunt, infertility for 3 years, teratozoospermia with 1% normal sperm, normal volume, great sperm density and mildly impaired motility; sperm defects primarily in the head but also in the center part, three times negative ICSI, fourth attempt imminent. Tendency to cold sensations, dry mouth and nose, pain in the LSC, chronic ischiatic complaints, bone and especially joint pain, frequent headaches, tinnitus, declining libido, previously longer periods of depression, ambitious, dogged, and restless; tongue: long and pointed, red tip, retracted tip and margins; pulse: tight. Qi and blood vacuity with kidney weakness and qi stagnation. Supplement comprehensively and move qi with Chinese medicinals and acupuncture; couple therapy. Natural pregnancy of the wife after 3 weeks and natural birth of a healthy, very strong son. Senior executive, age 37, 92 kg, 184 cm, slightly overweight, infertility for 3 years; one insemination, two ICSI, and one cryo attempt, negative in each case; OAT syndrome, last spermiogram severely curtailed in all parameters, varicocele II on the left. Pronounced cold sensations, thirst, tendency to moist hands, a lot of stress, stress-related pinched-off urination, frequent herpes labialis and nail fungus, bad hearing, ravenous hunger; tongue: pale, reddish margins, light indentation in the center and short furrow, dental impressions. Weakness in the center, qi stagnation and blood stasis, vacuity of qi and kidney, especially of kidney yang, damp-heat. Support the center and kidney and move qi with Chinese medicinal therapy; couple therapy. Natural pregnancy after 7 weeks and natural birth of a healthy son. Civil servant, age 30, 172 cm, 70 kg, infertility for 2 years, hormone therapy for the partner unsuccessful; oligozoospermia (0% normal sperm, defects in the tail and especially head), reduced concentration (9.7 million/mL) with normal volume and limited motility; in addition varicocele II-III on the left; after consultation with a fertility center, the couple chose TCM as an alternative. Largely inconspicuous; the patient merely reported occasional cold sensations and in the course of treatment also reduced libido. Insufficiency of kidney yang and blood stasis. Supplement qi and support yang with Chinese medicinal therapy. A control spermiogram after 60 days showed an increase in sperm concentration to 17.8 million/ mL, with clearly improved motility (40% lively) and lightly reduced malformation rate (1%). Consequently, the treatment principle was adjusted to addressing varicocele with insufficiency of yang: continue supplementing qi and yang and move blood more strongly. After a good 3 months and an additional seven formulas, the patient decided to undergo embolization of the varicose veins in the testicles. In retrospect, it turned out that his wife was already pregnant at the time of his surgery. The wife, who had had clear signs of heat, had previously been treated for 3 months. Treatment was continued up through the 12th week of pregnancy. Pregnancy and birth proceeded without complications; a healthy daughter was born. The experiences described below are based on the treatment of 53 men in 102 infertility cases, between October 2002 and June 2006. The age distribution is shown in Figs. 19.3. The youngest man was 27 years old, the oldest 52. By far the largest group consisted of 35-39-year-olds. Eighty-five percent of cases consisted of couples who had mostly been infertile for years and had already tried different measures of artificial fertilization without success (Figs. 19.4). Many wanted to go through additional measures from the very beginning. Fig. 19.3 Age distribution of the men.
Hans-Joachim Stelting
Infertility—a Special Challenge
Causes of Male Infertility
Diagnostics and Diagnoses of Male Infertility
Western Diagnostics and Diagnoses
TCM Diagnostics and its Most Relevant Diagnoses
Vacuity Patterns
Repletion Patterns
Treatment of Male Infertility
Biomedical Therapies
TCM Therapies
Medicinal Therapy
Medicinals
Guiding Formulas
Acupuncture, Ear Acupuncture, and Moxibustion
Combined TCM Therapy in Accordance with TCM Diagnoses
Insufficiency of Kidney Yin
Acupuncture
Insufficiency of Kidney Yang
Acupuncture
Moxa
Damp-heat
Acupuncture
Qi Stagnation
Acupuncture
Blood Stasis
Acupuncture
Lower Jiao Blood Stagnation (Varicocele)
TCM Therapy in Accordance with a Spermiogram
Low Volume
Treatment Principle
Low Motility
Treatment Principle
Malformations
Treatment Principle
Lower Jiao Blood Stegnation (Varicocele) in Oligospermia
Treatment Principle
Case Studies
Case Study 1
Medical History
Symptoms
Diagnosis
Therapy
Result
Case Study 2
Medical History
Symptoms
Diagnosis
Therapy
Result
Case Study 3
Medical History
Symptoms
Diagnosis
Therapy
Result
Case Study 4
Medical History
Symptoms
Diagnosis
Therapy
Result
Practical Experiences
Results of a Study
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