A Theoretical Review And The Clinical Application Of Acupuncture In The Treatment Of Female Infertility

In recent years, the utilization of acupuncture in gynecological health, especially in the treatment of infertility has been increasing outside of Asia. Amongst the Traditional Chinese Medicine (TCM) modalities, the acupuncture is one of the most utilized and sought after treatment of choice in female infertility. Several factors exists in this phenomena:first, the reproductive endocrinologists in the Western world highly discourage their patients to take any internal medicine with which they are not familiar, hence leaving out the option of using herbal formulas. Secondly, due to more acceptance by the patients in the West, the acupuncture has become much more main stream and commonly utilized than herbal medicine has outside of Asia. Thirdly, although many patients express the concerns about the safety and purity of herbal medicine, most have no such concerns regarding acupuncture. Because of this trend, more research has been conducted into use of acupuncture to improve many conditions including infertility. With its long history in treating gynecological problems including infertility in TCM, it is not by accident that acupuncture gained its popularity in treatment of female infertility. TCM have been used in China as the primary medical system to treat infertility until modern times. In TCM, a woman is more identified with Blood and a woman’s pathology is associated with pathologies of Blood. The Blood as the central idea of female disorder and regularity of menses in the core of female reproductive essence are still a part of modern day TCM gynecology practice.The modern research has shown that acupuncture alone can improve many aspects of fertility. These include:regulating menses and induce ovulation, especially difficulty to treat condition such as PCOS (Polycystic Ovarian Syndrome), improving blood flow to the pelvic organs, improving success rates of ART (Assisted Reproductive Technologies). As this author reviewed through the literatures in acupuncture and infertility, it is clear that acupuncture is indeed effective in treating variety of conditions associated infertility but there is not a well-defined treatment parameters in treatment of female infertility. Cochrane et al conducted a survey study of 23 acupuncturists from around the world with extensive experience in treating infertility in attempt to find an agreeable acupuncture treatment protocol for infertility. The study presented areas to be explored but did not specify the how the acupuncture treatments should be strategized to optimize the efficacy of acupuncture in treatment of infertility.The goal of this paper is to synthesize the acupuncture treatment parameters to optimize the female fertile potential-how acupuncture can best support the treatment of female infertility. This requires deeper understanding of acupuncture and infertility-both in TCM and Western paradigms. This paper explores the historical knowledge; the acupuncture organs, channels and vessels involved in female reproduction; and the current acupuncture research related to female infertility to support the synthesis of the proposed acupuncture treatment strategy to enhance women’s fertile potential. It is proposed that the parameters in which to optimize the female fertile potential with acupuncture treatment is multifaceted to best support the female infertility as a modality.The primary sources of information for this review study are journal articles and TCM reference and textbooks, which several are of direct translation of TCM books. Searches for this literature review included a web search in Google Scholar, Pubmed, Fertility journals and TCM journals. The key search words included:acupuncture and infertility, female infertility, acupuncture and assisted reproductive technologies to mention a few. Most of the articles are chosen within past 10 years of publication. Only the sources available in English are accessed for this review research.CHAPTER 1:BASIS OF UNDERSTANDING FEMALE INFERTILITY AND REPRODUCTION IN TRADITIONAL CHINESE MEDICINE AND WESTERN MEDICINEIn a female, two types of essence exists:pre-heaven and post heaven. The pre heavenly essence, which is more inherited with genetic association is stored in the Kidneys and is the foundation of a woman is seen as the menstrual blood, originates in the Kidneys. Kidney Jing, the essence is the basis of the female menstrual Blood. The post-heaven, or post-natal essence is acquired through surplus Qi and Blood, derived from the essence of food and liquid transformed via Spleen and Stomach. Hence the Spleen and Stomach are considered the post-natal root and is responsible for the proper supplementation and maintenance of post-natal essence and the Blood production.According to Suwen, At age 14, the Kidneys are exuberant, the Chong Mai is full, the Ren Mai is open, the Tian Gui, the heavenly water in form of menstrual Blood arrives, and the conception is possible for the female. The exuberance or the fullness of the Kidneys is said to be the result of postnatally acquired Blood and essence produced by the Kidneys. Therefore, the two main zangs in discussion regards to female fertility (healthy menstrual cycles) are said to be the Kidneys and the Spleen. Another important organ in female fertility (healthy menstrual cycles) is considered to be the Liver. Liver stores Blood, and in five phase theory, the Liver is the child of the Kidneys. It is said that the Liver and the Kidneys share a common source, which is Jing, the essence.In TCM, the Uterus is referred to as the Bao Gong, loosely translated as where the essence is treasured and stored. The Uterus is categorized as the extraordinary Fu-the Uterus stores like a Zang but the Uterus is hollow and discharges like a Fu. The Uterus is said to have connection to the Heart and the Kidneys through Bao Mai and Bao Luo, and connections to the channels and other network vessel to ensure that the Qi and the Blood are adequately supplied to the Uterus for menstruation and pregnancy191.Blood in the core of female reproduction, the regulation of menstrual cycle has been in the center of fertility treatment in TCM from ancient times to modern practice. Any menstrual disorders and pathologies such as excessive bleeding or lack of bleeding, painful bleeding, and no bleeding were carefully observed and the treatments rendered to establish the norm. Modern TCM female reproductive health provides a description for the menstrual cycle in different phases based on the changes in energy. As initially described in the chapter, just as Yin and Yang creates the whole, the menstrual cycle in TCM is the flow and receding tide of Yin and Yang with fullness and health of a single phase preceding and determining the advancement of the next phase. The Yin and Yang state indicated in the menstrual cycle determines the level of a woman’s reproductive health. According to Maciocia, regarding female reproductive health and treatment, the changes in energy are largely outlined as two stages:the Yin phase and the Yang phase. There is a possibility to conduct additional subdivision into four sub-phases, which last seven days each. In entirety, all the phases of the menstrual cycle are associated to the Yin, the Yang, the Blood, and the Qi on the womb with varying bodily processes.In sum, the menstrual cycle involves four stages:· The first stage is the menstrual phase. During this phase, there is movement of Blood, which is the purpose of the Liver Qi, and Blood should be flowing freely. The menstrual phase involves the transition from Yang to Yin where the Blood moves in a downward direction.· The second phase is the follicular phase. The follicular stage involves the Yin phase, which ensures the manufacturer of Blood and Yin. At the end of menstruation, it is the right time for Blood nourishment, particularly the emptiness of Liver Blood, and the supplementation of the Kidney Yin.· The third phase is the ovulatory stage. During this phase Yin and Blood slowly fill the Chong Mai and Ren Mai. It is important to note that it is at this stage that Yin switches to Yang-the transitioning of the Yin to Yang. In this stage, there is an adequate activity between Qi and Blood. The middle of the menstrual cycle is important in the solidification of the Chong Mai and the Ren Mai, and for the supplementation of the Kidney.· The fourth stage is the luteal phase. At this stage, there is significant increase in the Yang Qi and movement of the Liver Qi. Yin present but Yang more dominant. In the luteal stage, the most important aspect to note is that it is the Yang phase. During this phase, the fertile ovum is implanted and the duration prior to the beginning of the menstruation is appropriate for the supplementation of the Kidney Yang and for the regulate of Liver Qi.In TCM, the patterns of disharmony in female infertility are largely categorized to two main patterns:the pattern of Deficiency and the pattern of Excess. The deficiency patterns include:Kidney Jing deficiency, Kidney Yin deficiency, Kidney Yang deficiency. Spleen Qi deficiency, and Liver Blood deficiency. The excess patterns include:Heart Qi and Liver Qi stagnation, Blood Stasis, Phlegm Damp, and Cold in the Uterus. A recent survey observing the TCM pattern diagnosis of women with infertility by Coyle et al showed that the most common diagnosis was Kidney Yang Deficiency. They also found that more women with unexplained infertility were diagnosed with Qi stagnation in TCM diagnosis than any other pattern, and women with Western diagnosis of endometriosis had more diagnosis of Blood stasis or Qi stagnation according to TCM.The Western diagnoses of infertility are categorized to disorders of the ovulation (functional infertility) and the pelvic pathologies. The ovulatory disorders are anovulation, hyperprolactinemia, premature ovarian failure/resistance ovary syndrome, luteal phase defect, and Polycystic Ovarian Syndrome (PCOS). The pelvic disorders include endometriosis and pelvic inflammatory disorders.Another contributing factor to female infertility is aging. According to Evers, age and the duration of childlessness in females are the most important variables in the determination of fertile potential[10].American Society for Reproductive Medicine adds that the age-related decline in female fecundity and increased risk of spontaneous abortion are mostly linked to oocyte abnormality. The quality of oocytes in folliculogenesis is dependent on genetic, environmental, and in vitro culture effects. The vascular endothelia growth factor (VEGF) is a marker for angiogenesis. It has been found that the VEGF expression is higher in women of later reproductive age (38-46 years old) compared to the younger women. This increase in VEGF concentration indicates the hypoxia and less hospitable environment for the oocyte maturation. Because of the quality of oocytes from older women is compromised the pregnancy rate is reduced.According to Suwen, Tian Gui arrives at two sevens of age and at seven times five and seven times six, the peak fertility begins a gradual decline. The main sources of the Tian Gui-Kidney Jing and Spleen Qi-are depleting. Ultimately, the Kidneys will be completely depleted and will cease the provision of Jing to the Uterus and the formation of the Tian Gui. Therefore, Tian Gui completely ceases at the seven times seven according to the Suwen. This is a natural process of aging.Unlike the holistic approach to addressing infertility by addressing menstrual cycle, the Western medicine approach is reductionistic, unnatural, quick acting but with unwanted side-effects. The Western infertility treatments include oral medication to surgery, artificial insemination to In vitro fertilization, which can also result in preimplantation genetic testing and frozen embryo transfers.CHAPTER 2:ACUPUNCTURE CHANNEL THEORY AND ACUPUNCTURE RESEARCH RELATED TO FEMALE INFERTILITY AND REPRODUCTIONThe Jing Luo is a collective term for the channels that run through the body.’Jing’ refers to a path, track, or route. Jing is mainly used in reference to the Main and Divergent channels.’Luo’refers to the Connecting channels.The body consists of matter and energies that circulate through a network of channels (Jing), network vessels (Luo), and Organs. The channels also known as channels and the network vessels connect the body tissues. There are 71 channels in the body:The Jing Mai (12 Main Channels), Jing Bie (12 Divergent Channels), Jing Jin (12 Meridian Sinews), Qi Jing Ba Mai (8 Extraordinary vessels),15 Luo-Connecting vessels, and Pi Bu (12 Cutaneous regions).Maciocia indicates the reference of the Luo vessels and the eight Extraordinary Vessels (EV) predate the knowledge of the 12 primary channels. Contemporary understanding of these structures as a complex system emanates directly from the Ling Shu with corollary explanation in the Nan Jing. Both the Ling Shu and the Nan Jing regard the roles of these vessels based on the 12 main channels.The various meridian structures have unique history and functions. The 12 main channels have been accorded the most attention in the contemporary TCM, partially because they have the majority of points and also because of the emphasis accorded to them in the Ling Shu. Contemporary TCM emphasizes the diagnosis and treatment of Zang and Fu disorder patterns. The 12 main channels associate and link directly to the Zang and Fu organs maintaining and ensuring harmonious circulation and flow of Blood and Qi. It has been noted that the Liver, Spleen and Kidney channels and the acupuncture point located on these channels are important in treatment of infertility.The 15 Luo vessels are referred in classical texts and are, in most cases, referred to as the oldest acupuncture vessels. The points contain a complex system, mentioned in the Nan Jing and the Ling Shu. In spite of their significance, contemporary TCM accords them little focus. This may be attributed to different opinions on their structure and uses in treatment. It should, however, be noted that the Luo connecting points on the major channels could be regarded the most used category of points in contemporary TCM. The Luo Mai are linked with the main channels but more superficial than the main channels connecting the primary channels with the surrounding tissues. They connect Yin and Yang pairs providing nourishment, protection, warmth and Blood. Luo Mai points can stop bleeding both when it is caused by Qi deficiency and when caused by Blood Heat. The Luo Mai points that can be used to stop bleeding include HT-5 (Uterine bleeding), KI-4 (Uterine bleeding), and LR-5 (red vaginal discharge, Uterine bleeding). The Luo Mai points can also treat emotional disorders. Emotional stability is an important factor in female fertility. A Luo point such as PC-6 has a very dynamic psychological action in the movement of Qi on an emotional level, which stimulates the "coming and going" of the Ethereal Soul and lifts the mood.The Extraordinary vessels (EV) are discussed in both texts of the Nei Jing may be the oldest energy systems of the body. The EV act as the reservoir of Qi and have a particular relationship with the Kidneys. Of the eight EV, the Ren Mai, Chong Mai, Du Mai, and Dai Mai have extreme importance in the treatment of gynecology and female reproduction for they share the same source point between the Kidneys (except for Dai Mai). Li Shi Zhen quotes, "The EV are the root of the Great Avenue of pre-heaven, and Ren, Du and Chong are the source of creation."Ren Mai, also known as the’Sea of Yin’, has a close links to the Uterus and in the functionalities of the female reproductive system. Passage found in Ling Shu states that Ren Mai originates in the Womb/Uterus along with Chong Mai. Ren Mai is important in the regulation of Blood and Qi in the entire Yin channels, assists in the governing of menstruation, and controls the growth and development of the fetus, which ensure that the Ren Mai is one of the most important vessels in conception and the period of pregnancy.The Chong Mai is regarded as the most important and probably the original extraordinary vessel. Unlike Ren Mai or Du Mai, the Chong Mai does not have a clearly laid out point location. Modern understanding of Chong Mai trajectory is a compiled description of many classical texts including Suwen, Ling Shu, Nan Jing to name a few. Referred to as the’Sea of Blood,’the Chong Mai is responsible for Blood and Qi, and has a major effect on menstruation via the supply and coursing of Blood in the Uterus. The Chong Mai’s relationship to being referred to as the’Sea of Blood’is due to the fact that the Chong Mai is closely related to many functions of the Blood than any other channels of the body-controlling Blood of the Uterus and the transformation of the Kidney essence to Tian Gui; controlling all the Blood connecting vessels such as deep Luo-vessels; and it’s intimate relationship with the Heart.The Du Mai has the meaning of controlling, supervising and/or governing. Du Mai, also known as the’Sea of Yang channels’as a strong tendency towards strengthening the Yang of the body-the vitality. This may be a part of the reason why Du Mai maybe known as the’governing vessel’. As the channel trajectory presents, the Du Mai runs with the spine, nourishes the spine and the inner pathway enters the Brain and also nourishes the Marrow. With Du Mai’s connecting with Brain and the Heart, the Du Mai contains the consciousness and influences the mind. Du Mai represents the Kidney Yang in a menstrual cycle-Du Mai has the same origin as Ren and Chong Mai and strongly affects the Uterus and the menstrual cycle when there’s a background of Kidney Yang deficiency. Du Mai also has strong association with Ming Men-Ming Men is the root of the fire; Ming Men is the source of fire for all internal organs; warms the Uterus and essence, and harmonizes sexual function.The Dai Mai is generally translated as the girdle, or the belt and is the only channel that has horizontal trajectory. The Dai Mai surrounds and affects all the channels longitudinally-traverses the Du and Ren Mai through encircling the waist. The transformation of Dai Mai role is based in the life gate fire that manifests as the Yang Qi and the transformation and warming roles of the Liver, Spleen, Kidneys, and Heart both indirectly and directly in the Gall Bladder, Stomach, Intestines, and the San Jiao channels. Damage of the Dai Mai can affect the ability of the Spleen to ensure the transformation and transportation of food substances, which can lead to wetness (dampness) that can permeate downwards and result in disproportionate vaginal discharge patterns.Modern acupuncture research shows that acupuncture has effects on the central nervous system, immune system, endocrine system, neuro-endocrine system and psycho-emotional system, including stress and anxiety management. Acupuncture has been shown to be effective in induction of ovulation in numerous ovulation disorders such as Polycystic Ovarian Syndrome (PCOS). This has been well demonstrated by Stener-Victorin et al. and her several studies-the electro-acupuncture to the medial aspect of legs (SP-6 to SP-9) and lower abdomen (ST-29/28 and CV-3 and CV-4 vincinity) at low frequency (2-10 Hz) for 2-3 times per week for 14-16 weeks has shown to effectively induce ovulation, significantly lowered rate of body mass index (BMI), serum testosterone hormone biding globulin ratio, serum testosterone concentration, improved hyper-androgenism and menstrual frequency compared to the group that did not receive acupuncture. In some, the acupuncture treatments resulted in disappearance of multi-follicular pattern in the ovaries. These acupuncture treatments are also shown to increase ovarian and uterine blood flow essential in endometrial development and oxygen and nutrient support to the ovaries.One of the first studies of acupuncture examining the effect of acupuncture in assisted reproductive technologies (ART) is by Paulus et al. This pioneering acupuncture study of integrating acupuncture treatments pre and post In-vitro fertilization with embryo transfer (IVF-ET) showed that women who received acupuncture treatments resulted in significantly higher pregnancy rate versus women who did not. The acupuncture group received two acupuncture treatments on these points:25 minutes before (on the body, PC-6, SP-8, LV-3, GV-20, ST-29) and 25 minutes after (ST-36, SP-6, SP-10, LI-4) the embryo transfer.CHAPTER 3:CLINICAL APPLICATION OF ACUPUNCTURE IN TREATMENT OF FEMALE INFERTILITYChapter three presents acupuncture treatment points and protocols for a variety of fertility problems according to TCM pattern differentiation. The points were adopted from a variety of general and gynecological TCM texts available in the English language. The point prescriptions can be seen in table form starting on page 128 of the full manuscript.The problems and patterns that are presented are:●Ancient point selections for female infertility●Modern point prescriptions ○Deficiency pattern Kidney Jing Kidney Yin Kidney Yang Spleen Qi Liver Blood ○ Excess and full patterns Qi stagnation ● Heart Qi ● Liver Qi Blood Stasis Phlegm Damp Cold in the Uterus Blood HeatThe chapter then presents acupuncture point selection on the EV and their clinical significance. The EVs discussed are the Chong Mai, Ren Mai, Du Mai, and Dai Mai.Section two of chapter three presents acupuncture treatments to regulate the menstrual cycle. First, suggestions for treating according to the menstrual phase are presented, then specific treatments for different menstrual pathologies are presented.Section three presents suggestions for acupuncture treatment specifically to support ART procedures during the different stages of the procedures. Lastly, this chapter presents treatment suggestions for infertility related to advanced age.ConclusionThis paper reviewed both the classical Chinese references to gynecology in general and fertility specifically. Recent research regarding utilization and investigation of efficacy of acupuncture in treatments infertility related disorders and ART were also presented. From this latter part, it is clear that the acupuncture alone is effective in treatment of functional female infertility disorders and increasing pregnancy rate in ART.The stimulation of certain acupuncture points has been shown to improve blood flow, regulate menses, and improve implantation rates of IVF. However, the points utilized in these studies do not have a cohesive logic behind their selection. The points used tend to be on the trajectories of Chong Mai (and Stomach), Ren Mai, Du Mai, Bladder, Spleen, Kidney, Bladder and Liver channels. These points were most-often chosen because of the shared innervation or Western understanding of physiology/endocrinology with the reproductive organs as discussed in the section on acupuncture research. Acupuncture has greater effects than what the Western physiology understands. With a deeper understanding of how the channels are connected and how they function in concert, more-effective acupuncture treatment protocols can be postulated.First, regardless of the type of fertility issue being addressed, it is always better to initiate treatment as early as possible in treatment of female infertility. The studies also showed that frequency of the treatment is also a key factor in increased blood flow. The frequency should be at least two times a week for at least 12-16 weeks.Secondly, any menstrual irregularity and pathology should be addressed properly in order to maximize fertile potential. Zhu Dan Xi from Jin/Yuan Dynasty, quoted:"In order to cure infertility, the first important thing is to regulate the menstruation." In the practice of traditional TCM gynecology, the basic treatment methodology applied is ’bian zheng lun zhi’ - the treatment based on pattern differentiation. However, more contemporary practice of treating infertility are comprised of three components. First approach is based on the dictum’Kidneys rule reproduction(shen zhu sheng zhi)’,hence emphasis on treating Kidney on a routine basis regardless of the other treatment objectives. The second approach is the treatment based on Western pathologies of infertility (zhong xi yi jie he), the combined TCM and Western approach; but still treatment is largely based on pattern discrimination. The third is the treatment given according to the phases of the menstrual cycle where the treatment is determined and rendered based on the theoretical assumption and the pattern discrimination of a woman at different phases of the menstrual cycle. This is also found to be true in more recent survey conducted by Cochrane et al. This author believes that all of these components should be integrated in diagnosis and treating any menstrual irregularities to enhance fertile capacity for all these aspects are of importance.Thirdly, it is important to choose the most optimal acupuncture channels, acupuncture points, timing and frequency for optimal result. The channels and the network vessels not only provide Qi and Blood to the Uterus but these channels and network vessels connect, integrate and harmonize the whole body as this was explored through the primary channels, the Luo vessels and the extraordinary vessels. The channels connect the internal organs to the exterior, connect the internal organs to each other, connect upper and lower body, right half to the left half of the body, nourish and protect every part of the body in existence. Due to this intricate connection of the channel connection, the body is able to properly function and in a female, she is able to menstruate, conceive, and carry out the pregnancy. Any hindrance or insufficiency or blockage, whether it is externally contracted or internally created, could give rise to imbalances which can interfere with the proper communication between Zang Fu and the delivery of Qi and Blood. In a female, this can manifest as infertility.From the literature review in the paper, including both the traditional acupuncture point selection as well as the modern acupuncture research, the most commonly used acupuncture points in the treatment of female infertility lie on the channels of Liver, Spleen, Kidney, Bladder, Chong Mai, Ren Mai, Bladder, and the Du Mai. This is in agreement with the literature that the three most important organs in treatment of female infertility are Liver, Spleen (Stomach), Kidneys (Bladder) and the channels are Chong Mai, Ren Mai and Du Mai as mentioned above; and this channel selection in treatment of female infertility is deemed important.Lastly, it is also imperative that Shen is addressed in treatment of infertility. In summary, according to this author, important things to consider in the treatment of infertility are:· Timing and frequency of treatment 。Earlier onset of treatment is better 。Two to three times a week is better than once a week until ovulation and/or oocyte retrieval 。Integration of low frequency electro-acupuncture on the lower abdomen and the medial aspect of the legs during the follicle recruitment phase is of importance 。When down-regulated in preparation for an ART cycle, utilization of low frequency electro-acupuncture on the lower abdomen and medial legs alternating with lower back points (BL23-BL32) will be of help to increase the blood flow to the pelvic region-to the ovaries and uterus· Regulating menses and menstrual pathologies 。 Focus on the Kidney as it is the root of the fertile potential 。 Incorporate Western diagnosis into TCM pattern differentiation to add in-depth knowledge in diagnosis and treatment 。 Tailor treatment to the different phases of the menstrual cycle to increase the efficacy of the treatment-integrating acupuncture point selection listed in Chapter 3 according to menstrual phases will be of help during these phases· Proper acupuncture points and channel selection based on the TCM channel theory o Important channels in treatment of infertility are Liver, Spleen/Stomach, Kidney, Bladder; and Chong Mai, Ren Mai, Du Mai and Dai Mai o Acupuncture point selection on the lower abdominal region is important· Utilization of Ren Mai, Chong Mai, Du Mai and Dai Mai during an ART cycle o Especially useful during down-regulation when a woman’s natural ability to resume the cycle has been halted by drug manipulation o Selection of Chong Mai points (such as SP-4, PC-6, ST-30) are helpful post artificially induced menstrual bleed o Selection of Ren Mai points (such as KI-6, CV-3, CV-4) and Dai Mai points (such as GB-26) are helpful during the ovarian stimulation/hyper-stimulation o Around the time of oocyte retrieval, addition selection of Dai Mai points (such as GB-41, SJ-5, GB26 along with SP-9, CV-9) are helpful in remediating the discomfort of oocyte retrieval o Use of Du Mai points (such as application of moxa on GV-4) is useful during the luteal aspect of ART cycle· Treatment of Shen is important and should be included-especially in the luteal phase of the cycle o This is the most anxiety provoking phase of the menstrual cycle when women are trying to conceive. Addition of acupuncture treatments to calm the Shen will benefit to ease the tension during this phaseThis paper explored theoretical basis and treatments in female infertility in TCM from the classical writing to the modern research. The parameters in which to deliver the most optimal acupuncture treatments are multifaceted. The timing, the treatment frequency, incorporating the channel theory along with Eastern and Western understanding of infertility physiology, pattern diagnosis and individualized treatment plans according a woman’s cycle are of importance in improving the outcome of the treatment.One of the limitations to this review study is that this paper included the research and literatures available only in English. The future study can be more comprehensive if Chinese research and literatures on channel theory, acupuncture point selection, treatment of female infertility were included. Nonetheless, it is clear that acupuncture has a role in treatment of infertility and should be an integral part of infertility treatment plan in TCM.