Acupuncture and Clomid Therapy

1. Acupuncture and Clomid Therapy ------------ Evidence-Based Medicine 2-28-09

2. Case Study A 35-year-old female patient came in with infertility. She has been married for 7 years, but has no children yet. She’s been trying for years to get pregnant. When she checked with a western doctor, she had a right ovarian cyst and a low ovulation rate. She’ had her ovulations checked regularly, but she wasn’t ovulating during some months. Her husband also had check-ups and required tests done, but has no problems. The cyst was treated and removed 2 years ago, but she still could not get pregnant. Her doctor finally put her on Clomid therapy for infertility. One day, one of her friends told her about acupuncture therapy for infertility, and she is looking for alternative medicine to increase her chances of pregnancy.

3. PICO Model Clinical Question In patients with infertility due to ovary cyst and no ovulations, will acupuncture plus Clomid therapy increase the chance of pregnancy than acupuncture therapy alone?

4. Background of PCOS • Polycystic ovarian syndrome (PCOS) – one of the most popular diseases causing menstrual dysfunction and infertility • Endocrine and metabolic disorder • Still debate whether the primary cause of PCOS is in the CNS or ovaries • Long-term treatment required, or could lead to endometrial cancer, hypertension, and Type II diabetes

5. Background of PCOS Signs and symptoms: • Hyperandrogenism • Hirsutism • Hyperinsulism • Insulin resistance • Ovarian cysts • Anovulation • Menstrual dysfunction • Infertility • Acne • Obesity

6. Western Medical Treatments • Most popular choice for ovarian cysts and ovulation problems: antiestrogen drugs, esp. clomiphene citrate (Clomid) • Long half-life could deplete estrogen receptors and harm the endometrium and cervical mucus • Other side effects: nausea, ovarian hyperstimulation, and multiple pregnancies • Non-steroidal aromatase inhibitors, such as letrazole (Femara) and anastrozole (Arimidex)

7. Western Medical Treatments • Topitat et al. (2008) did crossover study on the effects of Femara and Clomid on superovulation, endometrial thickness, and hormonal levels: • Subjects: 22 Asian women with normal ovulation • One group took Clomid while the other took Femara for 1 menstrual cycle • Stop treatment in their 2nd cycle, then the groups switched drugs • Clomid yielded more mature follicles and higher estrogen levels than Femara

8. Western Medical Treatments • Wu, Wang, Cheng, & Hsieh (2007) compared results of Clomid and Arimidex on ovulation and hormone levels: • Subjects: 33 women with infertility • One group Clomid, other group Arimidex • Clomid resulted in quicker and higher development of mature follicles, but poor endometrial development and no pregnancies while Arimidex resulted in less mature follicles, but better endometrial development and 2 pregnancies

9. Acupuncture and Moxibustion • In TCM, PCOS caused by Shen deficiency, blood stasis with dampness and phlegm, and LV qi stagnation • Acupuncture treatment focused on tonifying Shen, circulating blood, removing dampness and phlegm, and soothing LV

10. Acupuncture and Moxibustion • Song, Yan, Wu, & Hou (2006) in review article: acupuncture more effective than Clomid and other western drugs • Stener-Victorin et al. (2000) conducted a non-randomized longitudinal study on the effects of electro-acupuncture on ovulation: • Subjects: 24 women with PCOS and amenorrhea or oligomenorrhea for 9 months • 19 subjects Clomid-resistant • 9 women had increased ovulations after EA, and 7 were Clomid-resistant

11. Acupuncture and Moxibustion • Song, Zheng,& Ma (2008) compared effects of acupuncture and Clomid on infertility and ovulation: • Subjects: 2 groups of 60 women • One group received Clomid while other received acupuncture and moxa • Acupuncture and Clomid both resulted in increased ovulation with no significant difference (p > 0.05), but acupuncture resulted in significantly higher pregnancy rates than Clomid (p < 0.05)

12. Conclusion • No articles about the effects from combining acupuncture and drugs for ovulation and infertility could be found, so clinical question could not be directly answered • Available articles showed acupuncture had better effects on pregnancy in women with ovarian cysts than Clomid or other drugs • Clomid not as effective as Arimidex, but better than Femara • Acupuncture with Clomid could possibly enhance treatment on infertility than acupuncture alone • Acupuncture to stimulate ovulation and maintain good endometrium, and Clomid to help with ovulation

13. References • Stener-Victorin E, Waldenstrom U, Tagnfors U, Lundeberg T, Lindstedt G, Janson PO. Effects of electro-acupuncture on anovulation in women with polycystic ovary syndrome. Acta Obstetricia et Gynecologia Scandinavica. 2000; 79: 180-188. • Song JJ, Yan ME, Wu XK, Hou LH. Progress of integrative Chinese and Western medicine in treating polycystic ovarian syndrome caused infertility. Chinese Journal of Integrative Medicine. 2006; 12(4): 312-316. • Topipat C, Choktanasiri W, Jultanmas R, Weerakiet S, Wongkularb A, Rojanasakul A. A comparison of the effects of clomiphene citrate and the aromatase inhibitor letrozole on superovulation in Asian women with normal ovulatory cycles. Gynecological Endocrinology. 2008; 24(3): 145-150.

14. References • Wu HH, Wang NM, Cheng ML, & Hsieh, JN. A randomized comparison of ovulation induction and hormone profile between the aromatase inhibitor anastrozole and clomiphene citrate in women with infertility. Gynecological Endocrinology. 2007; 23(2): 76-81. • Song FJ, Zheng SL, Ma DZ. Clinical observation on acupuncture for treatment of infertility of ovulatory disturbance. Zhongguo Zhen Jiu. 2008; 28(1): 21-23.