Abstract

Introduction

Recurrent pregnancy loss (RPL) is estimated to occur in 1%–3% of all pregnancies.1 Other estimates indicate that anywhere from 12% to nearly one-third or one-half of all miscarriages occur without a patient's knowledge, appearing like late menstruation.2,3 Evidence supports an increased risk of miscarriage as females age, with women ages 18–20 having a 12% chance of miscarriage. As women age, it incrementally increases to a 25% chance in women ages 40–42 and 50% or more in women ages 43–46.2,4,5

While a great deal of research supports the relationship between maternal age and miscarriage, some research is now suggesting that paternal age may also play a role.6,7 Women with male partners over age 35 have more than twice the risk of miscarriage, compared with women who have younger partners.8

By definition, miscarriage is a pregnancy that is involuntarily terminated before 20 weeks of gestation or if the fetal weight is below 500g.2,4 A loss of pregnancy after 20 weeks is considered a premature birth or stillbirth. The cause is generally different than a loss prior to 20 weeks.2,4 After three previous losses, the chance of miscarriage is 30%–45% and varies with the number of previous live births: If there were no previous live births, then the chance is 40%–45%; if there was one or more live births, then the risk of pregnancy loss is ∼30%.2,4

While age is a considerable factor, there are several reasons for a spontaneous loss, including fetal genetic abnormalities, anatomical factors, immunological factors, endocrine imbalances, bacterial infections, environmental toxicities, and lifestyle factors.2,4,5

In Traditional Chinese Medicine (TCM), the Kidney Essence (Jing), Yin, Yang, and Qi provide direction, energy, and substance to the reproductive system.5,9,10 The quality and balance of these energies determine egg health in the female and sperm health in the male. TCM theory states that a decline in the vital energies is a significant contributing factor to miscarriage but is not the primary reason. Multiple miscarriages are also known as hua tai, or slippery fetus, and can also be caused by pathological factors.11

Essence, Yin, Yang, and Qi naturally decline with age, but can be accelerated as a result of poor self-care, overworking, poor diet, drug/alcohol abuse, unresolved emotions, and/or excessive stress.

There is currently insufficient evidence to support the use of TCM as a treatment for RPL, but recent research suggests that acupuncture could play a role in preventing miscarriages in women undergoing in-vitro fertilization (IVF). In one abstract, it was noted that acupuncture performed on patients (N=114) prior to IVF resulted in fewer miscarriages.12 In another similarly designed study by the same researchers, an acupuncture group had significantly fewer miscarriages than a no-treatment group.13 Clearly, more research is needed. The aim of this article is to report the reproductive outcome of a 42-year-old female who was diagnosed with RPL and diminished ovarian reserve (DOR), and treated with TCM.

Case History

A 42-year-old female presented with RPL in June 2006. At her initial visit, she reported that she had had six pregnancies, two live births (1995 and 1998), and four miscarriages of fetuses that were between 6 and 8 weeks' gestation. The first miscarriage was in 1994 during a previous relationship. The next three miscarriages occurred in November 2005, January 2006, and February 2006, respectively. Her reproductive endocrinologist found that her follicle stimulating hormone (FSH) was elevated on day 10 (16 mIU/mL, normal range is below 10) via a clomid challenge test. She also reported that her progesterone level was low in the luteal phase, but no laboratory values were provided.

She started receiving a protocol for six consecutive cycles from November 2006 to June 2007. The protocol required she take 50 mg of clomiphene citrate on cycle days (CD) 3–7, confirm ovulation via an ovulation-predictor kit (OPK), and try timed intercourse. For her luteal phase, she was prescribed 200 mg of progesterone via vaginal suppositories 2 times per day and heparin shots two times per day daily. Clomiphene citrate is a selective estrogen receptor modulator that induces ovulation and may improve progesterone levels in the luteal phase.4 Progesterone administered exogenously supports early pregnancy until the placenta takes over at approximately 10 weeks of gestation. Heparin, a blood thinner, is administered in women with RPL to help prevent immunologically induced blood clots or inflammatory markers that can inhibit a viable pregnancy.4 Her reproductive endocrinologist was not hopeful and suggested that she consider IVF with a donor egg, which she and her partner declined.

The patient was a former athlete, who was lean and very fit with a normal body mass index. She exercised frequently by running, weight lifting, playing tennis, and bike riding. Her menarche was at age 13. Her menses were regular, occurring every 30 days. She reported a typical period as having a light-to-medium flow for 5 days, and she denied having clotting and cramps. The color of the flow was generally a “fresh” red, except that, on the last day, her flow turned to a pale brown-red. She confirmed mild bloating and irritability 2–3 days prior to onset of her menses. She believed that she ovulated between CDs 15 and 17 and confirmed this with an OPK. She reported minimal cervical fluid and an elevated libido. She denied having vaginal dryness or a need for lubricants.

In addition, she reported having frequent urination, nocturia, mental restlessness, irritability, cold hands and feet, thirst, postprandial gas and bloating, occasional loose stools, and elevated stress perception. She reported good energy and sleep. She denied night sweats, palpitations, digestive weakness, or pain. Her bowel movements tended to be daily and were easy for her to pass. Her partner's sperm analysis was better than normal in every parameter. She declined taking her basal body temperature as this induced stress.

Her pulses were thin and wiry overall, but were deeper and slightly weaker on her right. The chi positions were also slightly less forceful bilaterally than the other positions. Her tongue was pink, normally shaped, and slightly dry. Her sublingual veins were dark blue and mildly engorged.

Diagnosis

With trepidation, this patient began acupuncture at the behest of her yoga instructor. Because the patient was a former competitive athlete, she was unwilling to give up on solving her RPL problem without exhausting every option.

Motivation and vision despite facing struggles or obstacles are a benefit from the Wood Element. Her pulses were frequently wiry, with the exception of choppiness when she was miscarrying. The depressive aspect of an unfulfilled desire Stagnated her Liver Qi. Her perpetual movements forward in life, exercing, and attaining her goals had likely taxed her Kidney, making it insufficiently strong enough to govern reproduction and pregnancy.

Her diagnosis was mixed with Deficiency and Excess. She was Kidney Yin and Yang Deficient, with Liver Qi Stagnation agitating the Shen. The Kidney had signs of both Yin and Yang weakness. Urinary frequency, nocturia, cold hands, and feet show that the Yang is unable to warm the extremities and regulate urination. Restlessness, insufficient fertile cervical fluid, elevated libido, and thirst reveal the limited Yin available to moisturize and ground her. Irritability, premenstrual bloating, and elevated perception of stress combined with a wiry pulse show Liver Qi Stagnation. The Liver's inability to circulate Qi freely can also make it difficult to warm the extremities. Yin is needed to have high-quality eggs, estrogen, and a full lining of the Uterus in the follicular phase. Yin must transition easily, with assistance from the movement of Liver Qi to Yang in the luteal phase to warm the Uterus, allow embryo implantation, hold a potential pregnancy, and produce a good amount of progesterone.

Multiple pregnancies can deplete Kidney Yin and Yang. Multiple serial ovulation-induction cycles with clomid further assault the Kidney, making it difficult to recover.5,9 What is also noteworthy is the emotional upset caused by multiple miscarriages, which can Stagnate the Liver Qi and agitate the Shen. It is not surprising that this patient frequently exercised to aid movement of her Liver Qi. The inability to calm the Shen and mental restlessness may have compromised the Heart Qi, leading to the RPL caused by inappropriate opening of the Uterus and subsequent miscarriage.5

The treatment principle is to nourish Yin, warm and supplement Yang, course the Liver and calm the Shen. Treatment is adjusted to nourishing Yin in the follicular phase, coursing Qi to facilitate transition from Yin to Yang at ovulation, and warming and supplementing Yang by tonifying Yin in the luteal phase.

At the patient's initial visit, weekly acupuncture, with the addition of Chinese herbs, was recommended, as well as foot baths,9 yoga, and increased protein in her diet.

The patient provided written informed consent for this protocol.

Treatment: Acupuncture

In addition, R represents right and L represents left. The protocol is outlined in the sections below.

Menses Phase (CDs 1–4)

Follicular Phase (CDs 5–11)

Ovulation (CDs 12–19)

Luteal Phase (CDs 20–Onset of Menses)

Treatment: Chinese Herbal Therapy

All formulas are KPC granules (from Taiwan) in premixed formulas with single-herb additions. All herb functions were sourced from Formulas & Strategies,18 unless otherwise noted below. Daily dosage is 4 g dissolved in warm water, 2 times per day.

Menses Phase (CDs 1–4)

No herbal treatment was administered.

Follicular Phase (CDs 5–11)

The 10 g of Si Wu Tang contained: Shu Di Huang, Rehmannia radix (cooked), 25%; Dang Gui (Shen), Angelica sinensis radix, 25%; Bai Shao, Paeoniae radix alba, 25%; and Chuan Xiong, Chuanxiong rhizoma, 25%.

There was also a single-herb addition of 6 g of Sha Ren (Amomi fructus).

Yi Guan Jian was chosen for its ability to nourish Yin and circulate Qi. The addition of Si Wu Tangprovided extra Blood supplementation and movement. Blood and Yin are supplemented with the combination of these two formulas, with the addition of Sha Ren to aid digestion of the rich tonics.

Ovulation Phase (CDs 12–19)

Yi Guan Jian was chosen as the base formula for its ability to circulate Qi while nourishing Yin. Gou Qi Ziand Tu Si Zi were added to supplement the Kidney Yang, Essence, and Yin. The next three herbs are used to circulate Qi in the Lower Jiao to support ovulation. Xiang Fu circulates Qi in the Lower Jiao. Wu Yao is warm, circulates Qi, and opens the collaterals. Wang Bu Liu Xin moves Blood and also opens the collaterals. Sha Ren (Amomi aids digestion and harmonizes the middle Jiao.

Luteal Phase (CD 20–Onset of Menses)

In the luteal phase, Yang is at its fullest, supported by Yin, Blood, and Qi. Zuo Gui Wan nourishes the Yin to support the Yang.5 Additional Yang tonics Tu Si Zi and Xu Duan were added to support the Yang during its peak. Xiang Fu ensured that the Qi did not Stagnate and Sha Ren aided digestion of this formula.

First Pregnancy after TCM

Shou Tai Wan tonifies and stabilizes the Kidney to prevent miscarriage and calms the fetus. The herbs collectively tonify Yang, Yin, and Blood. The additions were included to address the Middle Jiao and prevent nausea.

She, unfortunately, miscarried a fifth time at 4.5 weeks' gestation in September. At this time, she stopped Shou Tai Wan and was advised to wait a minimum of 2 months before trying to conceive again; this was advised to supplement the Kidney, resolve any post-miscarriage Blood Stasis, regulate the Liver, and support the Shen. Her pulses were choppy and deep.