Fertility

Understanding Fertility

Fertility is the ability to conceive and carry a pregnancy, and infertility is defined as not becoming pregnant after 12 months of regular, unprotected intercourse.^[1] Infertility affects roughly 8% to 12% of couples of reproductive age worldwide.^[2] A male factor is the sole cause in 20% to 30% of cases and contributes to about half overall.^[2]

Common symptoms

Many fertility problems cause no symptoms, and the first sign is simply that pregnancy does not happen. Irregular or absent periods can point to a problem with ovulation, and painful periods may suggest a condition such as endometriosis.^{[1, 2]} In men, an abnormal semen analysis is the usual sign, and pain or swelling in the genital area should be checked.

Causes and risk factors

The most common causes are ovulation problems, male factor infertility and blocked or damaged fallopian tubes, and about 15% of couples have no identifiable cause.^[1] About 70% of women who do not ovulate have polycystic ovary syndrome (PCOS).^[1] Endometriosis, uterine fibroids and premature ovarian insufficiency can also play a role.^[2]

Age matters. In women, fertility starts to decline around age 25 to 30, and more steeply with age, and smoking and obesity can lower fertility.^{[1, 2]}

How it is diagnosed and treated conventionally

Evaluation usually looks at ovulation, the fallopian tubes and uterus, and semen quality, and about 85% of couples have an identifiable cause.^[1] Treatment depends on the cause and the woman's age.

Clomiphene, letrozole or gonadotropins induce ovulation, and for unexplained infertility, endometriosis or mild male factor infertility, a few cycles of ovarian stimulation may be tried before IVF.^[1] IVF is considered sooner for women over about 38 to 40 and is indicated for severe male factor infertility or untreated blocked tubes on both sides.^[1] Gonadotropins can cause multiple pregnancy and ovarian hyperstimulation syndrome, which your fertility specialist will monitor.^[1]

Why Fertility calls for a whole-person approach

Fertility depends on more than one organ. Hormones, ovulation, sperm quality, the uterus and tubes, age and general health all contribute, and either partner can be involved.^{[1, 2]}

Care that addresses stress, sleep, weight, smoking and overall health is therefore a reasonable complement to the medical work-up, though none of it replaces it.

Hormones and ovulation

Ovulation problems account for about 25% of infertility diagnoses.^[1] Hormonal conditions such as hypogonadotropic hypogonadism and high prolactin can affect fertility in both women and men, and PCOS is another cause in women. These conditions need medical testing.^[2]

Weight, smoking and lifestyle

Smoking and obesity can lower fertility.^[1] Lifestyle factors and chronic diseases are among the factors affecting the fertility of both men and women.^[2]

Stress and emotional strain

Fertility treatment itself is stressful. A review of eight trials found IVF patients have high levels of state anxiety around embryo transfer and egg retrieval.^[3] Researchers have also proposed that psychological stress could affect the ovary through oxidative stress, although this is a hypothesis and not proven in people.^[4]

Male factors

Men contribute to about half of all infertility, so a semen analysis is an early test for couples trying to conceive.^[2]

Acupuncture for Fertility

What the research shows

Acupuncture has not been shown to raise live birth rates in IVF, and its role in other situations is uncertain. The strongest evidence is negative. A randomized trial of 848 women having IVF in Australia and New Zealand found live births in 18.3% with acupuncture and 17.8% with sham acupuncture, a difference that was not statistically significant.^[5] A Cochrane review of 20 trials also found no evidence that acupuncture improved live birth or pregnancy rates in assisted conception, with low-quality evidence.^[6]

Results are more positive outside IVF, but the studies are weaker. A meta-analysis of trials in infertile women not having assisted reproduction found higher pregnancy rates with acupuncture or acupuncture plus other treatment than with Western medicine alone. The authors noted that all trials had unclear risk of bias and that publication bias may be present.^[7] A scoping review reported that most research focuses on PCOS and ovulation disorders and that studies of other causes were insufficient.^[8] In anovulatory infertility, a meta-analysis of nine trials found no added benefit when acupuncture was used with clomiphene, though acupuncture alone was associated with a higher pregnancy rate than clomiphene alone, and the authors urged caution in interpreting the results.^[9]

For PCOS, a Cochrane review of eight trials found that live birth, ovulation and pregnancy did not clearly differ between real and sham acupuncture, and that adverse events were probably more common with real acupuncture.^[10] For men, a meta-analysis of seven small trials found that the evidence does not support acupuncture as an effective treatment for low sperm count or poor motility.^[11]

Acupuncture may help with the stress of treatment. A meta-analysis of eight trials found a small reduction in IVF-related anxiety with acupuncture compared with controls, although the certainty of the evidence was very low.^[3]

How acupuncture may work

A proposed mechanism is that acupuncture changes beta-endorphin production, which could affect the hormone that triggers ovulation, but this has not been shown to improve fertility outcomes in trials.^[10] We do not claim that acupuncture improves egg quality, sperm quality or implantation.

What treatment involves

Treatment uses fine, sterile, single-use needles, usually left in place for about 20 to 40 minutes, over a series of visits with reassessment. Some trials gave acupuncture during ovarian stimulation and before and after embryo transfer.^[5] If you are having IVF, tell your fertility clinic that you are receiving acupuncture.

Serious problems from acupuncture are rare. In prospective studies, about 9 in 100 patients had a minor reaction such as brief bleeding, soreness or redness at a needle site, and serious events occurred in about 1 in 10,000 patients.^[12] Tell the practitioner first if you are or might be pregnant, have a bleeding disorder, take blood thinners, or have a pacemaker (relevant to electroacupuncture).

Ayurvedic medicine for Fertility

The Ayurvedic view

In Ayurveda, reproductive health depends on healthy reproductive tissue (shukra and artava dhatu), regular digestion and a calm mind, and traditional care often follows a preparation phase before conception. These are traditional ideas used to choose treatment, not biomedical findings.

Therapies that may be used

Care is individualized and traditionally combines:

• Diet and daily routine, such as regular meals, steady sleep and stress-reducing practices
• Herbs such as shatavari and ashwagandha, which are traditionally used for reproductive health
• Warm oil massage and relaxation practices

Panchakarma, a set of cleansing procedures, is not appropriate during pregnancy, and we would not use it while someone is actively trying to conceive or having fertility treatment, or during acute illness or frailty. Transdermal medication therapy, in which an herbal preparation is applied to the skin, may be discussed, but no evidence for it in fertility was found.

What the research shows

The research is limited. A literature review of Ayurvedic herbs in female reproductive health, covering tulsi, ashwagandha, ginger, turmeric and shatavari, concluded that further rigorous trials are needed.^[13] A review on shatavari, a traditional Ayurvedic tonic, proposes it may act by lowering oxidative stress, but notes that its action on the ovary remains poorly understood.^[4]

For men, a systematic review of 14 trials in idiopathic male infertility reported positive results for several herbal products, including Withania somnifera (ashwagandha) root and some Ayurvedic powders. Its abstract did not report live birth or pregnancy outcomes, so it cannot show that these products help couples conceive.^[14] No clinical trials of Panchakarma for fertility were found.

Herbal medicine for Fertility

Herbs and formulas that have been studied

Chinese herbal medicine is the most studied herbal approach for female infertility. A review of trials found the most commonly used herbs were Cuscuta chinensis (tusizi), Angelica (danggui) and Cyperus rotundus (xiangfuzi), used mainly for patterns described as kidney deficiency, sometimes with blood stasis or phlegm-dampness.^[15] Practitioners choose and adjust formulas for each person.

What the research shows

The evidence is limited and of low quality. A meta-analysis of 18 trials with 2,662 women found that herbal medicine increased pregnancy rates compared with placebo. The authors judged the reporting quality of the trials as poor, although risk of bias was generally low, and called for better-designed studies.^[15]

For PCOS-related subfertility, a Cochrane review of eight trials with 609 women concluded that there is insufficient evidence to support Chinese herbal medicine. It found only low-certainty evidence that adding herbs to clomiphene may raise pregnancy rates, and no data on live birth.^[16] For male subfertility, a Cochrane review found low to very low certainty evidence that oral antioxidant supplements may raise pregnancy and live birth rates. The result for live birth was not seen when high-risk-of-bias studies were removed.^[17]

Safety and herb-drug interactions

Herbs are active substances and can interact with medicines. Reviews describe interactions such as extra bleeding with warfarin and danshen or ginkgo, and lowered levels of other drugs with St. John's wort.^[18] Herbs and supplements account for about 20% of drug-induced liver injury in the United States, and multi-ingredient products are the most common cause.^[19] About one fifth of Ayurvedic medicines bought online contained detectable lead, mercury or arsenic.^[20]

If you are trying to conceive or already pregnant, many herbs are not suitable, and the Cochrane review of Chinese herbs in PCOS found too little safety information to say whether they are safe.^[16] Please tell us about every medicine and fertility drug you take, and whether you are in an active treatment cycle.

Translating traditional medicine into modern biological language

This is interpretation, not equivalence. Chinese medicine often describes fertility problems as kidney deficiency, blood stasis, qi stagnation or phlegm-dampness.^[15] Researchers study ideas that loosely parallel these, such as ovulation and hormone signaling, blood flow to the uterus, oxidative stress and the body's response to stress.^{[4, 10]}

Ayurveda's emphasis on tissue nourishment, digestion and a calm mind is similarly interpreted as general health, nutrition and stress. No study has shown that a dosha or pattern corresponds to a specific biological process in fertility.

How this care fits with your medical care

Complementary care is used alongside your physicians, not in place of them. Keep your gynecologist, reproductive endocrinologist or urologist involved, and do not stop or change fertility medicines, or delay testing or treatment, on the basis of complementary care. Age affects fertility, so delays can matter.^[2]

We do not diagnose the cause of infertility. Please bring your test results, such as semen analysis, hormone levels, imaging and any treatment plan, together with a full list of medicines and supplements. Tell your fertility clinic if you start acupuncture or herbs.

When to seek urgent medical care

Some symptoms in someone who is trying to conceive or having fertility treatment need immediate attention.

• Sudden or severe pelvic or abdominal pain, especially with dizziness or fainting, which can signal an ectopic pregnancy or a ruptured cyst
• Vaginal bleeding that soaks a pad every hour, or bleeding with a positive pregnancy test
• Rapid weight gain, a swollen belly, nausea and vomiting, or trouble breathing during or after ovarian stimulation, which can signal ovarian hyperstimulation syndrome^[1]
• Severe pain or swelling in the testicle
• Fever with pelvic pain or unusual discharge

If any of these occur, call 911 or go to the nearest emergency department.