A female patient mid 30’s came into the New York City acupuncture clinic wanting assistance with the current IVF cycle. She had been trying to get pregnant for the past year without success. During her early visits she felt frustrated with the IVF process because she didn’t develop as many follicles and had to undergo an additional IVF cycle to harvest more eggs. In fact during the first cycle she developed 23 follicles in total with 17 on the right side and 6 on the left side. According to her physician, 32 follicles are considered normal. In terms of symptoms, she had a regular monthly cycle with some mild to moderate cramping that was located below the umbilicus. During her cycle she experienced bloating and digestion issues such as diarrhea alternating with constipation. She also mentioned she would get random pain in the abdomen around her umbilicus which was not always related to her menstrual cycle. In addition during the past few periods but in particular with the last IVF cycle she experienced nipple soreness and breast distention. 3-5 days before her cycle she experiences extreme mood swings and has been diagnosed with PMDD.
She had a history of cysts on the left ovary, which did not impair follicular development and had chronic appendicitis secondary to endometriosis. In 2011 she underwent an appendectomy. Since this appendectomy she began experiencing the random abdominal pain. During her college years, she experienced frequent UTI’s and pyleonephritis.
Channel palpation revealed impairments in the following channels:
Hand and Foot Taiyin (lung and spleen)- Spleen 8 and Spleen 9 tender, the entire area from Sp-6 to SP-9 had nodules. The lung channel was tight with some nodules
Hand and Foot Shaoyin (heart and kidney) – Kidney 7 had an abnormal thickening of tissue
Hand and foot Shaoyang – SJ was tight with tenderness along GB 37 and GB 41
Hand Taiyang had a nodule at SI-3, UB 23 was tight
Jueyin: Liver 5 nodule and tender with the left side more sensitive
Abdomen: cold around umbilicus and qi jie restricted., scar tissue along the northern border of umbilicus
Analysis:
If there are any acupuncturists who are reading this, I would like to ask you given her history and the channel impairments where every channel has some pathology, where would you start? In terms of TCM she has multiple issues involving the liver, kidney, and spleen/pancreas. She has a kidney deficiency based on her history of frequent UTI’s, and difficulty conceiving, she has liver qi stagnation based on the PMDD diagnosis as well as liver overacting the spleen as evidenced by the digestive issues during her menstrual cycle. She mentioned previous acupuncture targeting the spleen 8 and spleen 9 areas because it was tender and she had a tendency towards dampness, yet when I examined this area, the tenderness remained unchanged.
In the Neijing we understand which symptoms belong to certain channels based on the channel routes and detailed history. Given her history, symptoms, and channel examination, the following channels are impaired:
Liver – PMDD, ovarian cysts, endometriosis, nipple soreness
Gallbaldder – breast distention, constipation
Spleen/Pancreas: Digestive issues, abdominal pain around the umbilicus, appendicitis
Kidney: frequent UTI’s in college
In this case it appears that the first channel that was thrown off is the liver channel because of the longstanding PMDD, cysts, and endometriosis. The liver channel enters into the pubic hair, then the genitals, which involve both external and internal genitalia. This includes the ovaries in females and testicles in males. Since her left liver 5 remained more sensitive, this indicates that the ovarian cysts on the left remain present. Treating the nodule and resolving the tenderness at liver 5 should resolve the cysts. The liver belongs to the eastern direction and is related with the season of spring. During the spring time plants begin to grow as energy ascends from the ground to the sky. Endometriosis indicates that the eastern energy of growth is uncontrolled. Because of the impairment in the east, the northern kidney direction remains stuck. This manifests as heat as the north fails to transform into the east (water nourishes wood) based on the 5 directional movements, resulting in frequent UTI’s.
The appendectomy impaired the spleen channel/center direction and caused the invasion of cold in the abdomen. The stomach channel passes alongside the umbilicus while the spleen sinew channel binds below the umbilicus. The heart sinew channel binds above the umbilicus, which is important to address because the heart nourishes the spleen. Usually chronic pain is caused by cold stagnation, which is often externally acquired. She mentioned having abdominal pain randomly as well as increased digestive issues these past 3 months.
Treatment:
The treatment is based on the principles of 5 phase motion. In this diagram, the organ systems have special relationships. The first relationship is the generating cycle. The generating cycle shows how one organ system nourishes and helps the following organ system's growth. This is represented by the outer circle: wood generates fire, which generates earth, and so on. If growth remains uncontrolled in any system it will throw off the entire body. Therefore, the second cycle (inner star) demonstrates how each system will restrict the growth of another one. Both nourishing and controlling cycles will occur simultaneously in a healthy person. If one system is unhealthy rather than moving across the generating cycle is will move along the controlling cycle and impair growth of the following system.
As mentioned in previous blogs every channel enters into the abdomen and connects with the respecting organ. If the digestion is off, nothing works, the organs do not function properly. In her case the direction of presentation is in the east (wood) with the infertility issues, and issues with the endometriosis, cysts, and PMDD. The direction of cause in this case is unknown, she may have been born with a weakened eastern constitution since these issues started around puberty. The direction of treatment is the center (earth). Based on the 5 directional chart, the eastern and center directions are in conflict (liver overacting on spleen/wood controlling earth). Secondly, if the center is impaired and doesn’t move into the western direction, it travels horizontally and restricts the kidneys. Removing the cold in the abdomen is the first priority and treating the center direction is primary. This will allow the conflicts between the liver, spleen and kidney to lessen.
Once her digestive issues and pain resolved, I began treatment of the liver channels. Ligou liver 5 directly affects the ovaries as the tributary (luo channel) joins this region. Neiguan was also added to enhance jueyin function and alleviate PMDD symptoms. Since her digestion and pain improved, but cold remained, we continued to treat the cold impairments in the abdomen and began treating the scar impairments on the superior border of the umbilicus. Treating the eastern direction will enable the north (water) to transit into the east (wood) and allow the generating cycle to re-establish itself.
The last stage of treatment before embryo transfer involved direct treatment of the ovaries. It was believed that scar tissue impairments from endometriosis were inhibiting follicular growth. During this last stage, we opened the outflow tract of the abdomen and treated impairments on the lower right side of the abdomen. This was performed 3 days before her second check up. During her follow-up 3 days after the last acupuncture session, follicular growth increased from 8 follicles to 17 follicles almost matching her left ovary for a total of 35 follicles. The patient currently remains in treatment and will have the transfer performed within the next week. Because we have removed a significant amount of cold and have enhanced follicular functions, in addition to improving the general health of her abdomen including digestion, I believe she will have a successful IVF outcome.
Pre and post embryonic transfer will involve treatment of the eastern and northern directions as indicated by the channels. In this case, the lead pair of neiguan and ligou will continue to be used. Fuliu K7 will be added in addition to R4 and R6. Treating the cold impairment was of utmost importance in the initial stages. It allowed the abdomen to function, and enabled the circulation to flow freely to the ovaries making it more responsive to treatment as evidenced by the treatment 3 days prior to her second check up.
Update:
Our patient is doing well. She recently entered into the second trimester of pregnancy. During her follow-up she noted moderate nausea lasting a few hours every day until week 10 when the placenta fully developed. The nausea did not interfere with her ability to eat. Acupuncture was administered until week 8 to control her nausea and strengthen her digestion. Overall her digestive health is much improved. The areas of spleen 8 and spleen 9 have strengthened tremendously since first starting treatment and no longer remain tender. The left liver 5 region still shows tenderness indicating the left ovary may still have unresolved cysts. These were not treated during this time, instead I focused on continuing to treat the stomach (earth) and kidney (water) channels as indicated by channel palpation.