Electroacupuncture Effectiveness for Treating Idiopathic Male Infertility

Abstract

Background:

Male infertility accounts for ∼50% of all infertility cases. The reasons for male infertility may vary, and one of them is related to an idiopathic factor that may impair spermatogenesis. Acupuncture is one of the most well-known and widely accepted alternative treatments and is becoming known as an effective complementary therapy for infertility.

Case:

The case in this article demonstrated the effectiveness of electroacupuncture (EA) for improving male fertility by referring to the total motile sperm count (TMSC), sperm morphology and motility, DNA Fragmentation Index (DFI) of the sperm before and after EA, and pregnancy success in a couple with male infertility. Couples are given therapy with EA twice per week for up to 12 sessions and planned intercourse during the fertile period (ovulation). After planned intercourse, the wife became pregnant; an intrauterine gestational sac (GS) was seen on transvaginal ultrasound and her human chorionic gonadotropin urine test was positive.

Results:

The TMSC parameter, sperm morphology and sperm motility, post-EA DFI was improved, compared to pre-EA. The couple was became pregnant after undergoing EA 12 times to treat male infertility.

Conclusions:

This case illustrated that EA therapy for idiopathic male infertility has an effect toward improvement of the spermiogram test result, DFI, and success in achieving a pregnancy. However, further research is needed because there are many patients with different causes for their infertility.

INTRODUCTION

Infertility is a condition characterized by the inability of couples to achieve pregnancy after 12 months of regular unprotected sexual intercourse.¹ The condition affects 8%–12% of couples, and male infertility occurs in 20%–30% of these cases.² Among all causes of male infertility, 30%–40% have idiopathic infertility.³ Idiopathic infertility is diagnosed when infertility and a spermiogram test abnormality (oligozoospermia, asthenozoospermia, and teratozoospermia) are discovered; however abnormality is not found in physical, genetic-testing or in laboratory investigations. In most patients who have idiopathic infertility, commonly performed management is empirical.^3,4 This situation contributes to the low accomplishments resulting from infertility management. Therefore male infertility requires other approaches to treat it effectively.

Traditional Chinese Medicine (TCM) has been known for 3000 years and is growing rapidly in modern times. Based on TCM, infertility is caused by a vital imbalance and obstruction of Qi energy, as well as poor Blood circulation. The obstructed energy flow interrupts sexual and reproductive functions in both men and women.⁵ One of the commonly applied therapies from TCM is acupuncture. Until recently, acupuncture was considered to be a complementary therapy that could be performed along with common modern biomedicine approaches.⁶ Acupuncture promotes sperm repair by using acupuncture needles on meridian points to unblock Qi and to create balance within the body.⁷ TCM theory is based the principle of meridians, acupuncture points, and Blood flow. In previous research, the BL 23 (Shenshu), ST 36 (Zusanli), CV 1 (Huiyin), and CV 4 (Guanyuan) acupuncture points were effective for treating male infertility.⁸ However, further systematic reviews are needed to determine how electroacpuncture (EA) affects poor-quality sperm.⁶

CASE

The patients were a couple who had been married for 11 years did not have any children yet (no pregnancy had occurred).

The female patient, age 28, often experienced abnormal uterine bleeding (AUB) and was diagnosed with polycystic ovary syndrome (PCOS). The criteria for PCOS are absent menstruation/amenorrhea for 3 months; ≥12 immature follicles seen on transvaginal ultrasound (TVUS); clinical hyperandrogenism characterized by excessive hair growth on the arms and legs; and acne.⁹ AUB therapy consisted of a contraceptive pill to regulate her menstrual cycle and stimulating her ovaries with clomiphene citrate. This latter medication (10 mg orally per day) was given to her on the second day up to the sixth day of menstruation. Subsequently, 75 international units (IU) of follicle-stimulating hormone (FSH) were administered on her sixth menstruation day until a mature follicle was generated. After an 18 mm-follicle appeared, an injection of human chorionic gonadotropin (hCG) was given. IUI was performed after 36 hours. The first IUI was not successful and did not result in a pregnancy.

The male patient, age 29, had infertility, which was indicated from the abnormal result of a spermiogram (asthenoteratozoospermia). This condition was discovered on an ultrasound (US). His testicles were normal in term of size and echostructure, and there was no abnormality on his epididymis. However, there were varicoceles on both testicles. A basic hormonal examination revealed that his concentration of FSH was 1.29 mIU/mL and his testosterone level was 653 ng/dL. Further examinations of his sperm showed that his DNA fragmentation index (DFI) was 39% (the agreed cutoff value is a DFI >30%).¹⁰

There are 2 functions of semen in the testicles the production of (1) testosterone and (2) spermatogenesis. Male hypogonadism refers to a disorder of one or both functions.¹¹ Given that the husband had with normal testosterone levels, he was diagnosed with asthenoteratozoospermia and varicoceles on both testicles—normogonadotropin-hypogonadism.

The couple attempted to achieve pregnancy again after the failed first IUI. Both husband and wife were then given EA twice per week for a total of 12 sessions.

Acupuncture points were selected based on points that are often used to improve fertility or sperm quality successfully. These points were CV 4 (Guanyuan),^6,8,12,13 3 cun below the umbilicus; ST 36 (Zusanli),^6,8,13,14 over the lateral side of the anterior ligament 1 middle-finger width of the bilateral anterior tibial peak; KI 3 (Taixi) bilaterally,^6,13,15 mid-distance between the malleolus internus and Achilles tendon, as high as the peak of the malleolus internus; CV 6 (Qihai),^13,15 midline, 1.5 cun caudal of the umbilicus; SP 6 (Sanyinjiao),^6,13,15 3 cun proximal to the malleolus bilateral medial; ST 29 (Guilai),^6,16,17 1 cun cranial of the pubic bone and 2 cun lateral to the bilateral midline; and LI 4 (Hegu),¹³ the highest point of the bilateral musculi interosseus dorsalis.

These acupoints were located on both patients with both of them lying in a supine position. After an antiseptic procedure, the acupuncture needles (Huanqiu, China) were inserted gently. These needles are made of stainless steel, sterilized, and disposable, 0.25 × 25 mm or 0.25 × 40 mm, depending on the patient's until De Qi is achieved. For this couple, the needles were connected to stimulator electrodes (Hwato SDZ V, Shanghai China) for 15 minutes, at a continuous wave and a frequency of 2 Hz. After 15 minutes the stimulator was turned off, the electrodes were disconnected, and the needles were removed.

In addition to EA therapy, the female patient was also given 400 mg per day of vitamin E, and male patient was given 1 tablet per day of an antioxidant (consisting micronutrients and vitamins, as well as lycopene, l-carnitine, glutathione and Panax ginseng). During their 12 sessions of EA, the couple engaged in planned intercourse during the fertile period (ovulation).

RESULTS

Figure 1 shows the husband's DFI post-EA therapy. Figure 2 shows the wife's intravaginal US examination, revealing gestational sac.

FIG. 1.

Post electroacupuncture (EA) therapy DNA fragmentation index (DFI). The pre-EA DFI examination was 39%. Post 12 sessions of EA therapy, the DFI was 38%.

FIG. 2.

A gestational sac (GS) was visible on an intravaginal ultrasound examination. The diameter of the GS was 0.46 cm.

After their EA treatment, this couple achieved pregnancy without IUI intervention. This was confirmed by the wife's positive hCG level and the intrauterine GS visible on her TVUS at 5 weeks of gestation (Fig. 2).

The results of pre- and post-EA sperm analysis for the husband are shown in Table 1. The pre-EA results indicated that he had asthenozoospermia and teratozoospermia. Subsequently, the EA therapy was performed and a post-EA sperm analysis was performed. It indicated normozoospermia based on the 2010 World Health Organization criteria.¹⁸

Table 1.

Pre- and Post-Electroacupuncture Sperm Analysis

Parameters	Results
	Pre-EA	Post-EA
Sperm analysis
Microscopic concentration	160	100
Motility
A. Fast linear	8	37
B. Slow linear	14	6
C. Nonprogressive	6	17
D. Immotile	72	40
Conclusions
Normozoospermia		+
Asthenozoospermia	+
Teratozoospermia	+

EA, electroacupuncture.

The male patient reported that, while undergoing EA therapy, he felt relaxed, more energetic, and not easily tired. The first pregnancy of the woman who underwent the EA was healthy and no pregnancy complications occurred.

DISCUSSION

Idiopathic male infertility is commonly found in clinical practices.³ One of the theories that explain the occurrence of idiopathic male infertility is oxidative stress on the male reproductive system. Oxidative stress occurs when there is an imbalance in the concentrations of pro-oxidants and antioxidants. The various causes of oxidative stress are already known, and among them is an elevated testicular temperature.¹⁹ The role of temperature on spermatogenesis is extremely vital because spermatogenesis is susceptible to temperature changes.²⁰ One of the body's mechanisms to keep testicular temperature low is the vascular heat–exchange system on the pampiriform plexus, where there is a direct connection between the artery and the vein.²¹

In the current case, there was an abnormal spermiogram result showing asthenoteratozoospermia and an increased DFI. Oxidative stress is the most-common cause of an increased DFI, which subsequently generates asthenoteratozoospermia. EA therapy to the s abovementioned point appeared to improve the motility and morphology of spermatozoa, which in congruent with with a statement from Yao and Mills¹⁷ that there is a fertility parameter improvement that occurs.

The exact mechanism of the spermiogram-result improvement post-EA has not yet been discovered.¹² One of the possible mechanisms is that EA unleashes and improves blood flow through vasodilatation in the testicular blood vessels and epididymis.²² Blood-flow improvement in the reproductive organs is expected to optimize the mechanism of the vascular heat exchange system, which maintains optimal testicular temperature. Testicular temperature that is always well-maintained will optimize spermatogenesis and reduce the probability of oxidative stress.^22,23

Another potential mechanism that transcutaneous EA stimulation (TEAS) to BL 23 (Shenshu), ST 36 (Zusanli), CV 1 (Huiyin), and CV 4 (Guanyuan) may increase sperm count and motility in patients with semen abnormalities. TEAS may be associated with increased seminal plasma zinc; neutral α-glucosidase and fructose; increased regulation of integrin-binding protein 1; and decreased regulation of cyclin–dependent kinase 1 b.⁸ The juxtaposition of acupuncture points leads to vasodilation of blood vessels, including in the testicles and epididymis.²² EA to GV 20 (Baihui), CV 4 (Guanyuan), ST 36 (Zusanli), and SP 6 (Sanyinjiao) has increased spermatogenesis in mice.¹² ST 29 (Guilai) to maximize the effectiveness of treatment can increase spermatogenesis and sexual activity.¹⁶

Several reports have also stated that EA is able to balance the hormone concentrations inside the body.^22,23

Other benefits of EA for infertility management are inhibition of the central sympathetic nervous system modulated by the endorphin system. Acupuncture has been proven to modulate β-endorphin, lower excessive β-endorphin plasma, and reduce sympathetic activity.^24,25 β-Endorphin is produced and released from the hypothalamic nucleus, arcuate nucleus, and nucleus tractus solitarius. This hormone is also released into peripheral blood flow from the hypothalamus through the hypophysis anterior—a process regulated by corticotrophin-releasing factor, which is secreted by the paraventricular nucleus from the hypothalamus.

β-Endorphin in plasma is presumably related to hyperinsulinemia responses and stress. Stress increases the activity of hypothalamic–pituitary–adrenal (HPA) axis and decreases reproductive function. Hormones of the HPA axis are closely related to the hypothalamic–pituitary–gonadal (HPG) axis. Acupuncture influences the HPA axis by reducing cortisol concentration, and influences the HPG axis by modulating production and secretion of central and peripheral endorphin, thus, influencing secretion of gonadotrophin-releasing hormone from the hypothalamus and the secretion of hypophysis gonadotrophin.^26,27

CONCLUSIONS

The case indicates that it is possible for EA to be used as a therapy option in male infertility, since it can provide an alternative in improving sperm quality. However, it requires further study because there are many patients with different causes of infertility.

AUTHOR DISCLOSURE STATEMENT

No financial conflicts of interest exist.

FUNDING INFORMATION

Funding for this case study was obtained from the Penerimaan Negara Bukan Pajak (Number 260/UN27.22/HK.07.00/2021).

ACKNOWLEDGMENTS

The authors express their gratitude to the director of the Dr. Moewardi Hospital, Cahyono Hadi, SpOG (K), for supporting the work performed for this case study.