Andy Crimmel

Chad Conner

Manoj Monga*

Pacific College of Oriental Medicine

And the

*Division of Urology

University of California, San Diego

Correspondence:

Manoj Monga, M.D.

Division of Urology

200 West Arbor Drive (8897)

San Diego, CA 92103-8897

Introduction

            Infertility is a private, social and economic problem. Infertility is defined as the inability to conceive a pregnancy within one year. Twenty-five percent of couples will seek help for infertility at some point during their relationship. Over two billion dollars are spent in the United States annually on infertility therapies.

            Male factor infertility is contributory in at least 50% of infertile couples. Currently the therapy for male factor infertility focuses on intricate microsurgery to correct varicoceles or obstruction of the male reproductive ductal system. Additionally, there has been a strong shift away from evaluating and treating the male, and proceeding directly to expensive artificial reproductive technologies. 

            Prior attempts at medical therapy for male factor infertility have included hormonal therapy (GnRH agonists and antagonists, gonadotropins, anti-estrogens, testosterone, aromatase inhibitors), antioxidant therapy, antibiotics, corticosteroids, methylxanthines, vitamins, minerals and amino acids (zinc, arginine), and angiotensin-converting enzyme inhibitors. The observation that no medication is approved by the United States Food and Drug Administration for treatment of male infertility confirms the conclusion that adequate controlled studies of potential therapeutic agents are either lacking or failed to elicit a significant improvement in fertility.

            Male erectile dysfunction can be defined as the inability of a man to obtain penile rigidity sufficient to permit coitus of adequate duration to satisfy himself and his partner.  The personal and private nature of this problem has hindered accurate estimates of the true prevalence in the general population.  Current estimates suggest that 20 to 30 million Americans suffer from erectile dysfunction.  Recent advances in medical therapies for erectile dysfunction has raised public awareness of the condition, however many men shy away from conventional therapies due to concerns of side effects and lack of efficacy.  Long-term satisfaction with current therapies ranges from 40-70%.

            Acupuncture may represent an important therapeutic modality for male factor infertility.  The purpose of this paper is to provide an introduction to the history of Traditional Chinese Medicine (TCM) and the basic philosophy and principles used to understand male erectile dysfunction and infertility from an Eastern medical perspective.  Finally, a summary is presented of the available research evaluating the efficacy of acupuncture in the treatment of these disorders.

Acceptance of an Ancient Modality

Alternative or complementary medicine has become an increasingly popular option for many patients.  This trend is reflected in the 47.3% increase in total visits to alternative medicine practitioners, from 427 million in 1990 to 629 million in 1997, thereby exceeding total visits to all US primary care physicians.  In this same period of time, the estimated expenditures for alternative medical professional services increased 45.2% with an estimated $21.2 billion dollars spent including at least $12.2 billion paid out-of-pocket (1).  TCM is one of the treatment modalities at the forefront of this trend.  Of the techniques employed in TCM, the use of acupuncture for the treatment of pain is the best known.  Other techniques including moxibustion, herbal medicine, and massage play integral roles in traditional treatment of a broad spectrum of diseases.

After many years of growing public acceptance, Western scientists and researchers have begun to take an interest in evaluating and employing acupuncture in clinical practice.  In 1997, after reviewing the scientific evidence, the National Institute of Health (NIH) released a consensus statement concluding that acupuncture is a promising modality for treating a wide range of conditions including osteoarthritis, fibromyalgia, addiction, stroke recovery, post-operative and chemotherapy nausea and vomiting, and asthma.  The NIH noted that one of the advantages of acupuncture was its substantially lower incidence of side effects than many drug therapies and medical procedures which sometimes had no more supporting evidence than that of acupuncture therapy.

The NIH committee concluded that there was sufficient evidence to support the incorporation of acupuncture therapy into conventional medicine.  These conclusions were consistent with the stance adopted by the World Health Organization (WHO) in 1980 when it issued a list of forty diseases well suited to treatment by acupuncture.  Although male infertility and erectile dysfunction are not addressed in the NIH and WHO statements, these conditions appear in the earliest Chinese medical texts.  Over thousands of years, TCM theory has evolved a comprehensive framework for diagnosing and effectively treating sexual dysfunction.

A Brief History of Traditional Chinese Medicine

One of the world's earliest medical texts and the most revered of the Chinese medical tradition is The Yellow Emperor's Classic of Internal Medicine.  The authorship of this text is attributed to the Emperor Huang Di who reigned from 2696 to 2598 B.C.E.  It is likely that the text was formally compiled much later, most likely between 480 and 222 B.C.E. during the era of the Warring States.  Nevertheless, the text depicts a sophisticated medical philosophy suggesting a culmination of ideas and technical expertise developed over hundreds or thousands of years.

The medical philosophy and techniques of early TCM evolved out of careful observation and critical thinking, reinforced through empirical clinical experience in a process consistent with modern principles of the scientific method.  These practices spread throughout the Far East, most notably to Japan, Korea, and Tibet, where theoretical and technical refinements over the centuries have produced a variety of styles shaped by different cultures, yet retaining the original holistic essence of the Chinese philosophy.  In Eastern cultures, acupuncture and herbal medicine were and still are primary treatment modalities, employed to treat all types of disease from the common cold to life-threatening conditions.

Acupuncture was virtually unknown in the United States until 1972 when China opened its doors to the West.  It quickly captured the imagination of the American public although primarily for its ability to manage pain.  Over the years, the other equally important modalities of herbal medicine, moxibustion, and Tui Na massage have gained in popularity and the realization that TCM is not limited to the treatment of pain has become widespread.

In 1985, the National Committee for the Certification of Acupuncture and Oriental medicine (NCCAOM) administered the first acupuncture certification exam, establishing national safety, efficacy, and competence guidelines for the practice of acupuncture in the United States.  Currently, applicants for national certification must complete a full-time acupuncture program and demonstrate 1,725 hours of education including 1000 didactic and 500 clinical hours.  There are also provisions for certification via apprenticeship and professional practice and in many States acupuncture is considered within an MD's scope of practice with no additional training or certification.  The highest level of instruction recognized in the United States is the Masters degree.  The standards established by the Accreditation Commission for Acupuncture and Oriental Medicine (ACAOM) include 2,175 hours of instruction composed of 705 hours in oriental theory, 360 hours in western sciences, 450 hours in herbal studies, and 660 hours of clinical practice.  Most schools have additional requirements, requiring 2,800 to 3,200 hours of education.  The ACAOM is currently developing the standards for a 4,000-hour doctorate program in Oriental Medicine.

[http://www.acumed.com/acumed/caaom/standards.htm#educate]

The role of acupuncturists in the U.S. medical community varies from state to state.  A few states do not license acupuncturists.  Several states require acupuncturists to practice under the supervision of an MD.  In California, however, acupuncturists are considered primary care physicians and health insurance companies are recognizing that TCM is a safe and cost-effective alternative to certain drug therapies and medical procedures.  The positive results emerging from clinical research, the favorable stance the NIH has adopted, and the remarkable increase in demand for alternative medicine in the past decade suggest that acupuncture and TCM will remain a major component of the emerging complementary healthcare system.

Philosophy and Theory of Traditional Chinese Medicine

Man as a Microcosm of the Universe

TCM evolved out of the philosophy that human physiology and health were a reflection of the processes observed in the natural environment.  Consequently, the language of TCM relies heavily on the use of natural metaphors to explain biological processes.  For example, red eyes and a flushed face can be explained in terms of Heat rising from Fire in the body, just as the heat from an actual fire was observed to rise and scorch whatever was above it.  The treatment strategy in such a condition might involve cooling the Fire by employing techniques to nourish the Water of the body, essentially the same strategy used to put out a fire in the natural environment.

Yin and Yang

One of the most fundamental concepts in Chinese medicine is the idea that two opposite yet complementary forces underlie all natural phenomena.  These forces are called Yin and Yang and they represent polar opposite qualities such as cold (Yin) and hot (Yang).  By extending this idea, winter is considered a Yin season whereas summer is Yang.  The phenomenon of contraction or consolidation is Yin much as water solidifies into ice in the winter.  The heat of summer causes water to evaporate therefore expansion is Yang.  This is one example of how a simple pair of opposite qualities (hot and cold temperature) can be used to characterize events (summer and winter) as well as physical processes (expansion and contraction).  Yin is also said to represent substance or things at rest.  Yang is expressed as function or activity.  From a Western perspective, one understanding of Yin and Yang in the body might be the balance between anabolic and catabolic processes.  A state of homeostasis may be thought of as a perfect balance of Yin and Yang.  In order for a system to be in a catabolic state, there must be relatively more catabolism (Yang) then anabolic activity (Yin).  Therefore, repletion of one of the Yin/Yang paired forces results in a deficiency or vacuity of the other.  Yin is associated with substance and the fluids of the body.  In a patient with Yin vacuity, there are often pathologies with the body fluids.  There is relatively more Yang in these circumstances and the heat associated with the Yang is said to dry up fluids.

In TCM, disease is viewed as the result of disharmony or imbalance.  Although TCM treatments generally operate at a more complex theoretical level, the balance of Yin and Yang in the body is the ultimate therapeutic goal.

Qi

            Like the concepts of Yin and Yang, there is no direct translation for the idea of Qi.  The direct translation of Qi means "air" or "breath" and represents the vital energy that permeates the universe.  In the human body, Qi is the active principal underlying physiology and metabolism.  Qi is also responsible for warming the body, protecting the body from external pathogens, and producing and distributing fluids and blood.  There are many different types of Qi and each organ is said to have its own particular Qi enabling it to perform the functions for which it is responsible.  For example, the Qi of the Lungs facilitates respiration.  Lung Qi has a natural tendency to move downward.  When the Lung is weak, its Qi can become "rebellious" causing it to move upward rather than down resulting in coughing or difficulty breathing.  To supplement Lung Qi is to re-establish the normal direction of the Lung Qi and restore the proper function of the Lung

The Organs

Chinese physicians recognized the existence of the organs of the body and attributed functions to them, many in terms of natural metaphor.  In some cases these functions coincide with our modern Western understanding of organ function.  For example, the Stomach is said to be the cauldron in which food and drink are cooked over the digestive Fire until they are reduced to elements that can be assimilated by the body.  Heartburn and acid reflux were understood as an excess of this digestive Fire rising from the Stomach.  However, most functions attributed to the organs were based on the observation of patterns, many of which have no relation to the modern understanding of the organ's function.  It was observed that many people who had Stomach Fire also developed sores on their gums therefore it was inferred that there was a relationship or pathway between the Stomach and the gums.  If a certain area of the body reduced epigastric pain when stimulated, that area of the body was thought to be part of the Stomach system.  These reactive areas of the body became the basis of the acupuncture point system.  If a particular emotion was frequently observed in people who tended to develop epigastric problems, then the emotion itself was considered to belong to the Stomach.  An Organ, from a TCM perspective, represents a theoretical construct of physiological patterns that may, from the Western perspective, involve multiple organ systems. 

The two organs most commonly involved in the TCM understanding of male infertility and erectile dysfunction are the Kidneys and the Liver.  According to TCM physiology, these two organs are very closely related.  The Liver stores Blood and the Kidney stores the Essence Qi.  The Essential Qi of the male and female is what meets during conception to form a new life.  The concept of Essence, then, roughly corresponds to our modern understanding of male and female gametes.  The Liver Blood and the Kidney Essence are Yin in nature; hence the Liver and Kidney are said to be of the same source.  They mutually engender, nourish and support each other.  A weakness in one organ is often associated with imbalance in the other.

The Kidneys are said to govern water.  Much like the modern understanding of kidney function, one of the TCM Kidney's principal functions is the transformation of fluids into urine, which is then stored in the Urinary Bladder.  The processes of growth, development, and reproduction derive from the Kidney Essence.

            TCM physiology attributes the storage of Blood to the Liver.  Blood is closely related to the reproductive Essence stored by the Kidneys.  The Liver also governs free coursing.  This is to say the Liver's function is to make Qi move smoothly through the body.  The smooth flow of Qi ensures the proper functioning of all bodily processes.  If the Liver is vacuous in smoothing the Qi, the physiological consequences may be extensive, involving many other organ systems.  The channel or meridian of the Liver wraps around the genitals.  Therefore conditions involving the genitals are often associated with Liver dysfunction.

Pattern Diagnosis

Western diagnostic thinking tends to follow a linear process of isolating structural or biochemical causes at the root of a chief complaint.  A symptom is often reduced to an organ; an organ reduced to tissue, and a tissue to a pathological biochemical process.  The tissue may be excised or a drug prescribed to correct, compensate for, or mask a chemical imbalance.  A thorough Western intake involves asking the patient many questions but the intent is usually to allow the physician to narrow his or her focus of the problem.  In contrast, the questions asked by TCM physicians tend to expand on the chief complaint and derive a broader understanding of the context in which the disease process originated.

TCM diagnosis revolves around identifying patterns of disharmony.  The diagnostician must gather as much information through observing, interviewing and palpating the patient.  The TCM physician considers the organ correspondences for the various pieces of information gathered.  Eventually, an Organ or a number of Organs begin to emerge as components of the disease or disharmony.  The physician must then unravel the relationship between the Organs that is leading to the imbalance.  Each Organ tends to damage or over-control another Organ if its function is allowed to become excessive or replete.  Each Organ is also associated with another Organ, which it nourishes.  This is the case of the Kidney and Liver.  If the Kidney is vacuous, the Liver will tend to suffer from lack of nourishment. 

There are many common patterns of disharmony.  Sometimes a patient will present with a clinical picture closely matching a classically recognized pattern but the majority of cases usually require a sophisticated process of gathering seemingly unrelated data and synthesizing it into a consistent picture of the patient's health.  Diagnosis generally involves asking a series of questions concerning the overall state of the patient's health.  Based on the knowledge of organ correspondences, the physician organizes the presenting symptoms into an individualized TCM pattern.  The observed signs and the reported symptoms are pieces of a puzzle.  A single piece alone rarely means anything.  Lumping all the pieces of the puzzle together into one disorganized pile only makes the clinical picture more confusing.  The art of TCM involves the skillful synthesis of all the clinical data into a comprehensive picture of the patient's disease pattern.  Once this is accomplished, the proper course of treatment to bring the body back into harmony emerges.

In general, there are no simple correspondences between Chinese diagnoses and Western diagnoses.  A single Western diagnosis may be explained by a number of TCM patterns.  The following tables give a rough indication of what patterns may be involved in specific Western diagnoses of erectile dysfunction and infertility.  These tables are presented not as a tools for diagnosis but to illustrate the depth and breadth of TCM diagnosis and its applicability to the full range of diagnoses recognized by the Western understanding of erectile dysfunction and infertility.

Erectile Dysfunction

Infertility

Patterns of Sexual Dysfunction

            A complete discussion of the patterns listed above is beyond the scope of this paper.  Even if a patient's condition closely matches a classical pattern, there will be nuances, which can only be properly addressed by a complete diagnosis.  Specific patterns are usually part of a larger disharmony.  In particular, since the Kidney and Liver are closely related, sexual dysfunction commonly involves combinations of Kidney and Liver patterns.  From a TCM perspective, all contributing elements of a pattern must be addressed in order to effect a lasting change in the patient's health.  The following discussion focuses on a few common patterns and is presented to illustrate the rationale behind TCM diagnosis and treatment.

Patterns of Infertility

Male infertility can be the result of many factors including pathologies in the motility and formation of sperm as well as obstructions in the genitourinary system.

Vacuity of Kidney Yang Infertility:

Since the Kidneys are viewed as the source of the sexual Essence in the body, problems with sperm motility and formation are often association with Kidney vacuity.  Since Yang is associated with functional activity, vacuity of the Kidney Yang is one mechanism to explain insufficient sperm motility.  The general pattern of the patient's health will reflect other signs and symptoms of Kidney Yang vacuity.  Since Yang is associated with heat, a Yang vacuity condition will include cold phenomena.  This may manifest as facial pallor, fatigue, cold extremities, aversion to cold temperatures, dizziness, tinnitus, aching low back and knees.

Vacuity of Kidney Yin Infertility

Problems with the formation of sperm reflect a vacuity of the Essence.  Since the Essence is Yin in nature and associated with the Kidney, this pattern is vacuity of Kidney Yin.  Since Yin is associated with coldness, a vacuous Yin pattern will have relatively more Yang or heat signs associated with it.  Common signs and symptoms in a Kidney Yin vacuity pattern include the subjective sensation of internal heat possibly with malar flushing, dizziness, tinnitus, weakness of low back and knees, and sleep disturbances.

Dampness in the Liver Channel

The Liver is responsible for the smooth flow of Qi in the body.  When the Liver is vacuous and Qi does not circulate properly, the fluids of the body are not moved and transformed normally and pathology may result.  Congested fluids tend to become thick and viscous resulting in the obstruction of the proper flow of fluids including the Essence or sexual fluids.  Liver pathologies are often associated with emotional upset such as anger and frustration.  Other signs and symptoms associated with a Liver dysfunction include hypochondriac fullness or pain, and digestive difficulties. 

Patterns of Erectile Dysfunction

Listed below are a few patterns associated with the failure to achieve or maintain an erection as well as the phenomenon of premature ejaculation.  Several of these patterns have already been discussed as causes of infertility.  A vacuity of Kidney Yang, for instance, may be the root pattern for a wide variety of diseases.  In general, the treatment of Kidney Yang vacuity diseases will involve the use of some of the same acupuncture point combinations and utilize similar techniques but the treatment of a specific pattern will be tailored to the unique qualities of the specific complaint as well as the patient's constitution.  In cases where the root pattern was discussed in the infertility section, the more general accompanying signs and symptoms will not be duplicated below.

Vacuity of Kidney Yang

There is a Yang component inherent in the process of achieving and maintaining an erection.  This is reflected in the functional and circulatory activity required as well as the heat and warmth produced in an erection.  A vacuity of Kidney Yang is a possible pattern that may result in various degrees of erectile dysfunction.

Vacuity of Kidney Yin

In cases of vacuous Kidney Yin, the Kidney Yang will tend to be in relative repletion.  This repletion Yang manifests as heat, which may cause reckless movement in the orderly flow of the Essence.  The result of this heat agitation may manifest as premature ejaculation.

Fear and Fright Damaging the Kidney

The dominant emotion associated with the Kidney is fear.  This correspondence is perhaps most graphically illustrated by the incontinence experienced during a frightening experience.  The functions of the Kidneys are also impaired when a certain degree of fear is associated with sexual activity.  This is a relevant concern in situations where a man is overly concerned about his sexual performance or fearful about causing pregnancy or contracting a sexually transmitted disease.  There is generally no problem achieving and maintaining an erection outside of a situation involving sexual contact.

Liver Channel Damp-Heat Pouring Downward

Due to the same processes mentioned under Dampness in the Liver Channel, fluids may stagnate into Dampness and obstruct the vessels of the penis resulting in the inability to achieve erection due to a physical obstruction.  Accumulated Dampness tends to engender heat.  This condition is commonly related to emotional frustration or constraint as mentioned above.  Additionally, there may be signs of heat in this pattern including itchiness and possibly rash of the scrotum, reddish urine, and dysuria.  From a Western perspective, if there are prominent signs of heat in the genital region, infertility due to increased temperature of the testes may be a concern.

TCM Treatment Modalities

Over thousands of years, the relationships or correspondences recognized by TCM have given rise to a system of approximately 1,500 points many of which are organized along channels or meridians throughout various regions of the body.  Every Organ has an associated meridian, linking a series of points on the body.  Each point regulates some aspect of the functional activity of its corresponding Organ system.  Many of these points occur far from their areas of influence.  The point to sedate Stomach Fire (heartburn), for example, is located in the web of the second and third toes.

            The health of the body was thought to be the result of a balance between the physiological forces of yin and yang as well as the proper flow of Qi through the meridians and their corresponding Organ systems.  Acupuncture points may be thought of as control points to regulate this flow of Qi by bringing more of it to areas that are vacuous and dispersing excess when too much Qi accumulates and becomes stagnant disrupting normal function.  Many points also have empirical functions as well, which were recognized over countless years of clinical observation.

            The flow of Qi is influenced by the insertion and manipulation of fine needles at appropriate acupuncture point locations.  Moxibustion refers to the burning of the herb Mugwort or Folium Artemisiae Argyi over specific points during a treatment.  Moxibustion may be applied in a number of ways including burning the herb over a point without making contact with the skin or burnt on the handle of a needle inserted into an acupuncture point.  Fine grades of moxa may formed into cones and applied directly to the surface of the skin over a point.  In general, moxibustion has a warming effect, which is thought to tonify or strengthen the Qi dynamics of the system and promote movement or circulation of Qi and Blood.

            Herbal formulas constitute an important aspect of TCM treatment.  Individual herbs are organized into broad therapeutic TCM categories such as "Tonify the Yang" or "Nourish the Blood" according to the principle action observed by the administration of herb.  Additionally, each herb is understood to have a primary effect on one or more Organ systems.  Herbs also exhibit specific properties of temperature as well as qualities such as being bitter or aromatic.  These qualities and properties allow for a great degree of precision and sophistication in choosing an herb for a given patient and their specific condition.  In TCM, a single herb is rarely prescribed alone.  Even if a certain herb is particularly indicated for a patient, other herbs would be given to enhance the efficacy of the major herb or help moderate possible undesirable effects.  In the majority of cases, herbal formulas are prescribed which may consist of a dozen or more individual ingredients.  There has been an effort in recent years to evaluate the pharmacological properties of many herbs but the understanding of how herbs interact with each other in the context of complex herbal formulations is unclear from a Western scientific perspective.

Western models of acupuncture function

            The role of acupuncture in the reduction of pain is one of the modality's most widely recognized applications.  Reports of the use of acupuncture in surgical anesthesia in Chinese hospitals served as many Westerners' first introduction to the practice of TCM.  While there are no definitive explanations for acupuncture's analgesic effects, it has been hypothesized that acupuncture needles stimulate nerves in the muscles which transmit impulses to the spinal cord, midbrain, and pituitary resulting in the release of endorphins and monoamines, blocking pain messages.  MRI studies reveal increased blood flow in the thalamus and brain stem following acupuncture treatment in patient's presenting with pain.  Numerous clinical studies have demonstrated that acupuncture analgesia works significantly better than placebo and the efficacy of acupuncture analgesia in pediatric as well as animal studies reinforces this conclusion.

            While there is some general consensus regarding the mechanisms underlying the analgesic effects of acupuncture, there is little conclusive research to suggest how acupuncture might have a regulatory effect on systemic biological processes.  However, if acupuncture can cause the release of substances in the brain to block pain signals, it is reasonable to speculate that acupuncture may be able to stimulate the release or production of other substances in the body.  In recent years, the focus of research has expanded beyond acupuncture analgesia to include the evaluation of other effects induced by needle stimulation.  There is significant clinical evidence to suggest that acupuncture has a regulatory effect on the circulatory, endocrine, and nervous systems.

            In animal studies, needling of the point ST-36 resulted in increased leukocyte count, reaching its highest level three hours after needling.  Stimulation of non-acupuncture points showed no visible change in leukocyte count.  Five days of acupuncture treatment of patient's with pernicious anemia raised red blood cell counts from 1 ml/mm³ to 3.37 ml/ mm³ and increased hemoglobin levels from 30 to 70.9%.

            In the treatment of appendicitis, acupuncture therapy was shown to increase 17-hydroxycorticosterone steroid levels in the blood by as much as a factor of two or three.  Twenty-four hour urine counts of 17-hydroxycorticosterone and 17-ketosteroid were also generally elevated.  These results are consistent with increased secretion of ACTH suggesting that acupuncture has an affect on the pituitary-adrenal cortex system.  Acupuncture treatment of endemic goiter resulted in decreased levels of iodine in the urine and increased thyroid absorption of iodine.  Similar findings for both of these studies were reported in animal trials.

Acupuncture appears to have a homeostatic effect on the autonomic nervous system.  In animal studies, acupuncture was found to return blood pressure to normal level whether it was artificially raised by the injection of adrenalin or lowered by cholinergic drugs.  Similarly, when cholinergic drugs were used to strengthen intestinal peristalsis, acupuncture had a normalizing effect on peristaltic contraction.  In the treatment of gastrointestinal spasm, acupuncture raised parasympathetic tone, increasing the strength of peristalsis.

            A simple and popular hypothesis for these clinical findings is that acupuncture stimulates nerve receptors at point locations, transmitting signals to specific areas of the central nervous system, which initiate physiological changes in the body.  The reason certain points have these effects still escapes the modern scientific attempt to understand acupuncture outside of its historic theoretical context.  Nevertheless, researchers are confirming seemingly bizarre phenomena, which TCM considers commonplace.  A controlled, randomized study presented in JAMA found that burning moxa over an acupuncture point on the little toe was effective in correcting breech births.  A study of functional MRI scans revealed that the stimulation of acupuncture points located along the side of the foot traditionally used to treat visual problems, showed an increase of activity in the visual cortex of similar magnitude to scans on the same patients exposed to a flash of light.  Stimulation of a non-acupuncture point on the toe showed no response in the visual cortex.  These findings suggest that acupuncture is a promising modality for more than pain management.  Current research seems to raise more questions than it answers.  While it may fail to explain how acupuncture works, in many cases it appears to support the validity of the TCM understanding of human physiology.

Male Infertility Studies

Acupuncture

There has been no reported studies done on animals all were performed on humans.  There has been several studies done both in the east and west ranging from case study designs to the more traditional controlled studies.

There has been several case study designs done to test the effects of acupuncture on male infertility.  A small designs was done by Shealy comparing 6 college aged males with male infertility or hypospermia.  They found that 5 out of the 6 patients had improvement in sperm count and sperm quality.

Zhiyuan Q. (1996) developed larger a case study design using 54 males treating them with acupuncture. They fit in the criteria of low sperm count, poor sperm motility, or lack of liquefied seminal fluid. They were an average age of 35 and had an average of 20.5 treatments. The same five acupuncture points were used for each treatment.  After the insertion of needles, moxibustion (moxibustion treats and prevents diseases by applying heat to points or certain locations of the human body) was applied for 30 minutes. Of the 54 cases, 30 cases (55.6%) were cured, 13 (24.07%) were improved, and 11 cases (20.27%) were ineffective. The overall effective rate was 79.63%. The results were confirmed by laboratory examination. 

.  Jiasheng Z. (1987) researched 248 cases of male infertility using acupuncture. He divided the cases into 5 different Traditional Chinese Medical diagnoses. There were 4 basic points used for each treatment with the addition of symptomatic points. In weaker patients moxibustion was used. The patients were treated once a day for a course of 20 treatments. He found, after his extensive study, that 166 cases (73.6%) responded to the treatment showing reduced signs of infertility. 

 Xinyun H. from Chengdu School of Traditional Chinese Medicine performed a unique experimental design comparing a group of 54 males treated by acupuncture and the addition of medication to a group of 54 males treated only by medication. They were suffering from male idiopathic oligosprematic sterility.  The patients were randomly divided accordingly to odd or even date they came in to the hospital.  They all were administered 25mg of Clomiphene everyday for 25 days. This study differed form the rest by treating the patient for 3 months as one course because the sperm need 90 days to develop from spermatogonium to mature sperm. They found that with the use of acupuncture in addition to medication there was a 92.5% effective rate and the medication group a 74.1% effective rate.

Fishl F, (1984)  a study on 28 infertile males testing their semen count, concentration, and motility using acupuncture. Each patient received 10 treatments over a 3 week period. They checked the spermiograms and hormone levels before and after each treatment. All cases showed statistically significant improvement of sperm quality. To investigate further, written psychological tests were given before and after treatment. The tests showed no psychological change caused by acupuncture, therefore proving the increase in sperm quality is not a placebo-mechanism.

A study done on 30 males (Gerhard) showed a increase in semen parameters of motility and sperm count. The subject all had abstaines from andrologically effective medication for a minimum of 12 months. They collected sperm samples before, 1, 5 and 12 weeks following treatment. They performed 10 acupuncture treatments in an 2 week period.  They assessed by spermograms and hormone assays.  The strongest results were observed in the samples from week 1. The spermograms showed a improvement in sperm motility ?? and sperm count ?? .  The hormone profile rose significantly in testosterone levels (p<0.05) allowing an improvement in sperm motility. The hormone LH showed with the group that had low levels an significant increase during week 5.  The study lacked an control group to show any comparison or placebo effect.

Bartoov B, (1997) developed a controlled study to assess the effectiveness of acupuncture on the sperm quality of males suffering from subfertility related to sperm impairment. Both groups were 35.8 + 5.5 years of age and share the same statistical characteristics. They collected semen samples of 16 acupuncture treated subfertile males, treating them twice a week for 5 weeks, and semen samples of 16 untreated subfertile males as a control group. They analyzed the semen with routine and quantitative ultramorphological observations at 2-8 month intervals.  Specific combinations of acupuncture points were selected for each patient according to the principles of Chinese Medicine.  No more then 12 points were used per session. In the experimentally treated group, the fertility index expanded significantly (p < .05) in total sperm fraction, percentage of viability, total motile spermatozoa per ejaculation, and integrity of the axonema. 

A similar study was performed by Minhua assessing the effectiveness of acupuncture on sperm count, motility rate, movement below Grade III, and abnormal form in 39 males.  The males were an average of 31.3 years and diagnosed free from sexual dysfunction, cryptorchidism, varicocele, and maldevelopment of external genitalia. They treated them every other day for 90 days and used the same combination of acupuncture points for each treatment. Two points on the abdomen were needled to propagate a sensation to the genital region. The effects consisted of the sperm count increasing per ml to more than 20 million, spermatozoa motility rate increasing more than 20%, and the forward movement of spermatozoa was raised more than one grade. After acupuncture treatment for 120 to 240 days, the patients showed marked improvement in sperm count and motility from pre and post-treatment statistically (p < 0.001).

Even though all the studies showed a positive effect of acupuncture on male infertility many of the studies went by strict scientific rigor.  Most of the studies did not allow for the 90 day growth of sperm from spermatogonium to mature sperm. 

Chinese Herbal Studies

            As mentioned in TCM Treatment modality section, TCM is a multifaceted approach which includes herbal medicine which can be compared to the allopathic use of medications.  Several studies have been performed using TCM herbal formulas consisting of a combination of herbs in a formula, which is complied for a specific complaint.

            Chen R and Wen H conducted a study on male infertility of 202 patients using a Chinese herbal formula.  The patients were diagnosed under the pattern of Kidney Yang Vacuity (see related section).  The formula consisted of 15 medicinals and was administered twice a day for 60 days.  The patients were diagnosed with oligospermia and had not taken hormones or the herbal formula 2 months prior to the study.  They divided the patients in to 3 groups depending on sperm densities ranging from group 1 at 211.90x10⁴+137.85 x10⁴ to group 3 at 1621.86 x10⁴ +1098.50 x10⁴.  They tested for sperm volume, density, and activity along with the levels of testosterone, LH, and FSH. They organized the results under cured, effectively treated, somewhat effectively treated, and ineffectively treated.  60.9% or 123 people were cured which was defined as 40x10⁶ ml density of sperm, 2 ml sperm volume, activity 50%, grade III or IV sperm, pregnant spouse or child birth.  Effectively treated was 29.7% or 60 defined as 20x10⁶ ml sperm density, activity 50%, grade III and/or IV sperm.  Somewhat effectively treated was 6.4% or 13 patients defined as density of sperm doubled or still less then 20x10⁶ ml or density unchanged but activity doubled.  6% or 3 patients were ineffectively treated. 

Male Erectile Dysfunction Studies

Kho G, Sweep CGJ, Chen X, Rabsztyn PRI, Meuleman E (1999) conducted a pilot study of 16 patients suffering from erectile dysfunction.  They used the same eight acupuncture points on all patients treating twice a week for four weeks.  Low frequency electrical stimulation was used for thirty minutes on four of the acupuncture points during all the treatments.  Blood samples were drawn to test for stress hormones such as adrenocorticotropic hormone, gonadotrophines follicle stimulating and leutinizing hormones, and testosterone.  They evaluated the patients over a twelve week period and found erectile improvement in 15% and 31% reported increase in sexual activity.  In the final interview two months after the first treatment 39% still reported improvement in their sex life in terms of activity and global quality of erection.  The overall improvement rate was 54%.

Eur Urol 1994;26(1):52-5

The place of acupuncture in the management of psychogenic erectile dysfunction.

Yaman LS, Kilic S, Sarica K, Bayar M, Saygin B

Department of Urology, University of Ankara, Medical School Ibn-I Sina Hospital, Turkey.

Successful sexual functioning is a complex process involving psychological and social responses as well as neurological, biochemical and vascular processes. Today it is believed that more than 50% of the sexual dysfunction cases have an organic etiology. Reflecting the controversy over the management of psychogenic erectile dysfunction, there are several different methods which are currently in clinical use. In this prospective study we aimed to evaluate the curative effects of acupuncture therapy in men with purely psychogenic erectile dysfunction. Of the 29 patients treated with this procedure 20 patients demonstrated successful erections following a varYing number of acupuncture sessions. In the light of our findings we may conclude that acupuncture may be an effective alternative in the management of purely psychogenic erectile dysfunction.

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Conclusion

Reference List

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