Case Report: Acupuncture in Infertile Women of Advanced Reproductive Age with Low AMH

Female reproductive aging is a common cause of infertility in women in their late 30s and 40s [1] Because female fertility begins to decline in women of advanced reproductive age (≥ 35 years old), advanced reproductive age (ARA) is a risk factor for female infertility, pregnancy loss, fetal anomalies, stillbirth, and obstetric complications [2]. This article reviews on 10 clinical cases of Canadian women who are infertile due to advanced reproductive age with low AMH level (<1 ng/ml), and, who, after several failed IUI or IVF cycles, were treated with acupuncture for 3 to 6 months. All 10 women had spontaneous pregnancies and live births. Acupuncture is effective for patients of advanced reproductive aged with low AMH who did not respond to IUI or IVF protocol. Method: based on weekly treatments, the 12 course-treatment of acupuncture focussed on invigorating kidney qi and nourishing the spleen and stomach in order to increase the probability of the outcomes of pregnancy and live birth by regulating menstruation and ovulation, and improving egg quality.


The Kidneys Govern Reproduction
Traditional Chinese medicine believes that infertility is caused by mutations in Chong and Ren, the dysfunction of viscera, and the inability to take innate essence (Jing) in the uterus. The kidneys are the storage place for the vital essence (Jing), a subtle substance responsible for the growth, development, reproduction and fertility.
They are the source of yin and yang for all of the other organs. The kidneys are the source of prenatal qi, which is inherited from the parents and interpreted as a person's innate constitution. The kidneys govern the function and the control of the brain, Tiangui, Chong channel, Ren channel and uterus.

The Spleen is the Acquired Foundation
The spleen and the stomach are the root of postnatal qi in TCM. It is necessary to replenish the spleen and promote the transformation of the human body's subtle substances while invigorating the kidneys, so as to combine the innate and the acquired so that the innate and the acquired can nourish each other. However, the function of the spleen and stomach depends on the support and coordination of other organs. For the spleen to be healthy, it needs to be nourished by the kidney yang. If the kidney yang is insufficient, the Mingmen (vital gate) will fail, which also weakens the spleen yang.

The Liver is the Congenital Dependence of Women
The liver is the basis of the innate in women. The Chongmai originates in the uterus and passes through the liver. It is closely related to a woman's ability to conceive. The Chongmai communicates with the twelve meridians, which is the sea of twelve meridians. When the Taichong meridian is prosperous, menstruation is on time. This shows that the Chongmai is the foundation of menstruation.
Traditional Chinese medicine believes that the ability to conceive is most closely related to the health of the kidneys, spleen and liver. The kidneys are responsible for storing essence and are the foundation of reproduction. Therefore, deficiency of kidney qi is the foundation of infertility. The spleen is the foundation of acquired nature, which is responsible for digestion and absorption, which, in turn, transform nutrients into qi and blood. The liver stores blood and ensures the smooth flow of qi. If the liver qi stagnates, menstruation is disordered, and therefore it is difficult to conceive.

Acupuncture and Female Infertility
At present, most scholars believe that acupuncture increases the rate of pregnancy for the following reasons. Acupuncture has been proven to encourage the circulation of blood in the pelvic cavity and improve ovarian function [5]. Some studies have recommended that acupuncture can be beneficial in promoting follicle production [6], enhancing uterine blood flow, [7,8] improving uterine lining thickness9,, 10 and increasing endometrial receptivity during the implantation period [11,12] Acupuncture has also been counselled as a valuable alternative therapy for female infertility due to hormone disorders [13]. Acupuncture helps the woman's natural hormone cycle by influencing the hypothalamic pituitary gonadal axis (HPG axi--ovarian hormone feedback loops). Studies have also proven the positive effects of acupuncture on ovulation inductions [14][15][16][17].

Acupuncture Infertility Points
According to the theory of "Female Seven" physiological cycle in "The Inner Classic of the Yellow Emperor", acupuncture treatments focus on the kidneys, spleen, stomach, large intestine, and the Chong and Ren channels. Three groups of acupuncture points are needled bilaterally and alternately.

Manipulation
After disinfecting all points with a cotton ball dipped in alcohol, the order of inserting the puncture needles is from the lower limbs to the abdomen, starting on the left side and finishing on the right side. Disposable sterile needles, size 0.25x25mm, are used and are inserted perpendicularly in all points to a depth 10 to15mm. A KWD-

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I electro acupuncture instrument is connected at ipsilateral
Ki12 and ZIGONG, Baliao (Bl31-34), and set to a continuous wave, the intensity of which is based on the patient's preference. Needles remain inserted for 30 minutes each session, and a TDP lamp is used on the belly during the session. For auricular points, the pressneedle SEIRIN Pyonex is used and the needle size is 0.2mm×0.3mm.
Needles remain inserted for 24 to 72 hours.
During the treatment, all of the patients were told not to have cold drinks, raw food, or alcohol and to go to sleep before 11pm.

Discussion
Women begin life with a fixed number of eggs in their ovaries.
The number of eggs decreases as women get older. A woman's peak reproductive years are between the late teens and late 20s.
By age 30, the ability to get pregnant starts to decline. This decline becomes more rapid once she reaches her mid-30s. By 45, fertility has declined so much that getting pregnant naturally is unlikely for most women [18].
Ovarian aging will have begun before women notice any clinical changes to their menstrual cycles. Therefore, they are often unaware that they may be at greater risk of infertility. Ovarian function declines as women approach their later reproductive years until menopause. Consequently, increasing age is associated with lower fecundity and infertility. Women experience a decline in natural fertility that begins in the mid-30s, and they will often reach sterility many years before the complete cessation of menses [19].
In TCM, these observations were made in three major medical In the 1950s, Dr. Paul Nogier, a French neurosurgeon, published the auricular map called the "Embryo Reflection" which theorized that the outer ear represents an inverted fetus within the womb and, thus, proposed the somatotopic correspondence of specific parts of the body to specific parts of the ear [20] (Table 1). n. Note on Jan. 7, 2020: emergency C-section due to distressed breathing of the baby. Baby Sammy was born at 2:35 pm ( Figure 1).