**6. Acupuncture and moxibustion**

As with TCM and single Chinese herbal therapy, acupuncture and moxibustion have also been used to treat female or male infertility for hundreds of years. Traditionally, acupuncture and moxibustion were performed by inserting needles or burning moxa sticks into specific points (acupoints) on the meridians. Acupuncture and moxibustion work by regulating energy flow, also called Qi in Chinese, over the meridians. Newer therapeutic methods include electro‐acu‐ puncture (EA), laser‐acupuncture, burning moxa granules on the top of the needles, points pasting, and far‐infrared moxibustion. Some meridians or acupoints have been indicated for the management of gynecological or obstetric problems, and these include Taichong (LR 3), Taixi (KI 3), Sanyinchiao (SP 6), and Gongsun (SP 4). These points were the earliest recorded in the Chinese classic Huangdi Neijing (the Classic of Inner Canon of Huangdi) around the time of the Han dynasty, and in the Chinese classic Zhenjiu Jiayi Jing (the A‐B Classic of Acupuncture and Moxibustion) during the Jin dynasty.

#### **6.1. Male infertility**

Gonadotropin‐releasing hormone (GnRH) is released by the hypothalamus and stimulates ovulation and sperm production in women and men, respectively. Thus, its deficiency con‐ tributes to both male and female infertility [65]. One study showed that repeated EA on the arcuate nucleus (Arc) can regulate the function of the HPG axis by suppressing Arc discharge, serum testosterone, sperm count, and GnRH mRNA expression [66]. Therefore, electrical stim‐ ulation may be an effective alternative to medications to regulate the HPG axis [67]. Another clinical trial in humans showed that 10‐Hz EA stimulation of the abdominal acupuncture points ST‐29 (guilai) increased testicular blood flow (TBF), but simple needle insertion and 2‐ Hz EA stimulation did not [68]. The combination of acupuncture and moxibustion treatment has also been shown to increase the percentage of normal‐form sperm in infertile patients with oligoastenoteratozoospermia in a prospective, controlled, and blinded study, but the mechanisms remain unknown [69]. Another study revealed that acupuncture can improve quick sperm motility, increase the normal sperm ratio, and improve fertilization rates and embryo quality in cases of idiopathic male infertility with failed ICSI [70]. According to the results of a systemic review from China regarding the treatment of male infertility, acupunc‐ ture appears to be as effective as TCM and more effective than western medicine alone, and its ability to improve sperm concentration and increase the level of grade a pulse b sperm is increased when applied together with either TCM or western medicine [71].

#### **6.2. Female infertility**

*5.4.3. Herba Leonuri Japonici*

concentrations in uterine smooth muscle [64].

96 Chinese Medical Therapies for Diabetes, Infertility, Silicosis and the Theoretical Basis

Acupuncture and Moxibustion) during the Jin dynasty.

**6.1. Male infertility**

**6. Acupuncture and moxibustion**

Herba Leonuri Japonici, commonly called Chinese motherwort, originated from Leonurus japonicus Houtt (Labiatae). Related variants of this species include Leonurus sibiricus auct. pl., Leonurus artemisia (Lour.) S.Y. Hu., Leonurus heterophyllus sweet, and Stachys artemisia Lour [63]. According to the principles of TCM, Herba Leonuri Japonici promotes blood flow to regulate menstruation and induces diuresis to alleviate edema. It is also referred to as Yi Mu Cao in Chinese, which translates literally into "beneficial herb for mothers," and is used to manage dysmenorrhea, amenorrhea, menoxenia, lochia, edema, and other gynecological problems but is contraindicated in pregnancy due to the possibility of stimulating the uterus [63]. The aqueous extract from the aerial part of Leonurus artemisia has the potential to treat dysmenorrhea by increasing the serum progesterone level, inhibiting inflammation, relax‐ ing uterine spasms, and decreasing prostaglandin F2α (PGF2α) and prostaglandin E2 (PGE2)

As with TCM and single Chinese herbal therapy, acupuncture and moxibustion have also been used to treat female or male infertility for hundreds of years. Traditionally, acupuncture and moxibustion were performed by inserting needles or burning moxa sticks into specific points (acupoints) on the meridians. Acupuncture and moxibustion work by regulating energy flow, also called Qi in Chinese, over the meridians. Newer therapeutic methods include electro‐acu‐ puncture (EA), laser‐acupuncture, burning moxa granules on the top of the needles, points pasting, and far‐infrared moxibustion. Some meridians or acupoints have been indicated for the management of gynecological or obstetric problems, and these include Taichong (LR 3), Taixi (KI 3), Sanyinchiao (SP 6), and Gongsun (SP 4). These points were the earliest recorded in the Chinese classic Huangdi Neijing (the Classic of Inner Canon of Huangdi) around the time of the Han dynasty, and in the Chinese classic Zhenjiu Jiayi Jing (the A‐B Classic of

Gonadotropin‐releasing hormone (GnRH) is released by the hypothalamus and stimulates ovulation and sperm production in women and men, respectively. Thus, its deficiency con‐ tributes to both male and female infertility [65]. One study showed that repeated EA on the arcuate nucleus (Arc) can regulate the function of the HPG axis by suppressing Arc discharge, serum testosterone, sperm count, and GnRH mRNA expression [66]. Therefore, electrical stim‐ ulation may be an effective alternative to medications to regulate the HPG axis [67]. Another clinical trial in humans showed that 10‐Hz EA stimulation of the abdominal acupuncture points ST‐29 (guilai) increased testicular blood flow (TBF), but simple needle insertion and 2‐ Hz EA stimulation did not [68]. The combination of acupuncture and moxibustion treatment has also been shown to increase the percentage of normal‐form sperm in infertile patients with oligoastenoteratozoospermia in a prospective, controlled, and blinded study, but the mechanisms remain unknown [69]. Another study revealed that acupuncture can improve There is evidence to suggest that acupuncture stimulation of acupoints of the conception vessel, spleen, kidney, and bladder meridians improves clinical symptoms in patients with diminished ovarian reserve (DOR), and also lowers serum FSH, LH, and estradiol [E(2)] levels through regulation of the hypothalamic‐pituitary‐ovarian (HPO) axis [72]. A randomized, prospective, controlled clinical study revealed that acupuncture during the luteal phase of IVF/ICSI cycles increased clinical pregnancy and ongoing pregnancy rates [73]. Acupuncture improves IVF out‐ comes through four potential mechanisms: (1) by increasing blood flow to the uterus; (2) by reg‐ ulating neuroendocrinological factors and the ovaries; (3) by modulating cytokine levels; and (4) by decreasing levels of anxiety, stress, and depression [74]. A successful pregnancy relies on the presence of adequate uterine blood flow and endometrial thickness, and these factors are especially important in pregnancies conceived through IVF and ET [67]. A study of infertile women with a high pulsatility index (PI) and downregulated with a GnRH analog to exclude any fluctuating endogenous hormone effects on the PI, revealed that EA reduced uterine artery blood flow impedance [75]. However, the literature on the efficacy of acupuncture treatment for endometriosis, immune and pelvic inflammatory disease‐related infertility or subfertility is sparse. One study on women with steroid‐induced polycystic ovaries demonstrated that EA modulates the neuroendocrinological state of the ovaries by inhibiting endothelin‐1 and nerve growth factor (NGF), and NGF mRNA expression, most likely by modulating sympathetic activity in the ovaries [76]. Another similar study on estradiol valerate‐induced polycystic ova‐ ries demonstrated that EA treatments change the neuroendocrinological state in the ovaries by suppressing corticotropin‐releasing factor, which may play an important role in reproduc‐ tive failure [77]. Finally, the results of the Fertility Problem Inventory (FPI) and Beck Anxiety Inventory (BAI) questionnaires revealed that women suffer greater anxiety and sexual infertil‐ ity stress than men [78]. High levels of stress affect female hormone levels and disrupt ovulation by affecting the HPO axis [67]. These studies all highlight a need for additional research into the potential benefits of acupuncture and moxibustion for the management of infertile patients.
