Keywords: acupuncture; Chinese traditional medicine; infertility; moxibustion; oligozoospermia; teratozoospermia; semen

Abstract

Aim: To evaluate the effect of Chinese Traditional Medicine, acupuncture and moxa treatment, on the semen quality in patients with semen abnormalities. Methods: In a prospective, controlled and blind study, nineteen patients, aged 24 years ~ 42 years and married for 3 years ~ 11 years without children with semen abnormalities in concentration, morphology and/or progressive motility without apparent cause, were randomized into two groups and submitted to acupuncture and moxa treatment at the therapeutic (Study Group) and the indifferent points (Control Group), respectively, for 10 weeks. Semen analyses were performed before and after the treatment course. Results: The patients of the Study Group presented a significant increase in the percentage of normal-form sperm compared to the Control Group (calculated U=16.0, critical U=17.0). Conclusion: The Chinese Traditional Medicine acupuncture and moxa techniques significantly increase the percentage of normal-form sperm in infertile patients with oligoastenoteratozoospermia without apparent cause.

1 Introduction

It is known that men are responsible for 47 % of the infertility problems [1, 2]. Despite the scientific medical advances, 40 % of the infertile patients who present abnormal semen analysis remain with no definite etiologic diagnosis, making the clinical treatment limited and frustrating [3]. On the other hand, some authors have successfully treated patients with varicocele or prostatitis and semen abnormalities using techniques of the Chinese Traditional Medicine [4-7]. We have proposed this prospective, controlled and blind study on infertile patients presented semen abnormalities in concentration, morphology and/or progressive motility to evaluate if acupuncture and moxa treatments could improve the semen parameters.

2 Materials and methods

2.1 Patients

2.1.1 Inclusion criteria

Patients sought infertility treatment in the Human Reproductive Division of the Department of Gynecology and Discipline of Urology of the São Paulo Federal University Paulista School of Medicine between January 1999 and September 2000. Nineteen patients without children were included with semen abnormalities in concentration, morphology and/or progressive motility detected in 2 semen analyses at the Human Reproduction Laboratory of São Paulo Federal University. They were otherwise healthy. The patients were randomized into two groups: the Study Group [n=9, aged 24 years ~ 43 years (mean 33.4 years) and married for 5 years ~ 11 years (median 7.6 years)] and the Control Group [n=10, aged 26 years ~ 42 years (mean 31.6 years) and married for 3 years ~ 8 years (median 6.1 years)]. The clinical investigation was approved by the Institutional Review Board.

2.1.2 Exclusion criteria

Patients with sperm concentration<5×10⁶/mL, leukocytospermia, previous reproductive organ surgery or usage of drugs acting on the genito-urinary tract within 1 year were excluded.

2.2 Treatment

2.2.1 Study Group

Patients of the Study Group were treated with classic acupuncture and moxa (warming acupuncture points) at the therapeutic points (Tables 1 & 2). Stainless steel disposable needles (0.25 mm×30 mm, Lautz Company, Brazil) were used. Needle depth and direction at each point were in accordance with the acupuncture treatment fundamentals [9], obtaining needling sensation (Teqi) at each point. Moxa was applied up to the appearance of local erythema. For this, the artemisia wool (Chinese National Medicines and Health Products Imp. Exp. Corp. Human Branch, Beijing, China) were used. Each session of treatment consisted of 25 minutes of acupuncture and 20 minutes of moxibustion, twice a week. The whole treatment course lasted 10 weeks. After the treatment course, an additional semen analysis was performed by a technician not knowing the details of the patient.

Table 1. Acupuncture points. (from: Zhao JS. Chinese Acupuncture and Moxibustion. Shanghai: Shanghai University of TCM Publishing House. 2002; P 40-144).

E30 (Qichong)	R3 (Taixi)
E36 (Zu Sanli)	IG4 (Hegu)
BP6 (Sanyinjiao)	BP4 (Gongsun)
F3 (Taichong)	CS6 (Neiguan)

Table 2. Moxa Points. (from: Zhao JS. Chinese Acupuncture and Moxibustion. Shanghai: Shanghai University of TCM Publishing House. 2002; P 40-144).

B23 (Shen Shu)	VC6 (Qi Hai)	VC 5 (Shimen)	PC46 (Qimen)
B52 (Zhishi)	VC4 (Guanyuan)	P9 (Taiyuan)	PC49 (Zigong)
B22 (San Jiao Shu)	VC3 (Zhongji)	B13 (Feishu)
VG4 (Mingmen)	B20 (Pishu)	B14 (Jue Yinshu)
B32 (Ciliao)	B21 (Weishu)	B15 (Xinshu)

2.2.2 Control Group

The control patients had acupuncture and moxa treatment performed at non-therapeutic indifferent points. Four ventral acupuncture points, two over the anterosuperior iliac spines and two over the acromioclavicular regions and four dorsal moxa points, two over the scapula and two over the posteroinferior spine, bilaterally were selected. The procedure was similar to those of the Study Group. Similarly, a semen analysis was performed at the end of the course

2.3 Semen analysis

Semen samples were obtained by masturbation after 3 days ~ 5 days sexual abstinence. After 30 min of liquefation at 37 ℃, semen analyses were performed according to the laboratory manual of World Health Organization[8], while the sperm morphology was estimated as per Kruger et al [9]. Analyses were performed by two experienced technicians.

2.4 Statistical analysis

The Wilcoxon Tests [10] was used to compare the pre- and post-treatment data and the Mann-Whitney test[10] to compare the two groups in relation to the calculated percentage data. Nullity hypothesis rejection level was set in 5 %.

D % = (Post - Pre) ×100 %
Pre

3 Results

All patients completed the treatment, indicating a good patient tolerance to the procedure. However, statistical analysis was performed with 8 patients in the Study Group. One was excluded on account of incomplete seminal data.

The patients of the Study Group presented a significant increase in the percentage of normal-form sperm compared to the Control Group (Table 3). The comparison of other pre- and post-treatment data (volume, concentration, progressive motility and number of round cells) did not show significant differences between the two groups.

Table 3. Patients with semen abnormalities in Control and Study Groups according to the percentage of normal-form sperm observed in the pre- and post-treatment periods.

	Control			Study
	Pre	Post	D%	Pre	Post	D%
	10.00	3.00	-70.00	1.50	7.00	366.67
	1.50	1.00	-33.30	7.50	8.00	6.70
	7.00	7.00	0.00	4.00	6.00	50.00
	4.00	3.00	-25.00	2.00	2.00	0.00
	4.00	5.00	25.00	6.50	8.00	23.08
	4.50	7.00	55.60	6.00	8.00	33.33
	5.00	0.30	-94.00	4.00	4.00	0.00
	1.00	1.00	0.00	6.50	5.00	-23.08
	7.00	0.70	-90.00
	4.00	3.00	-25.00
Mean	4.80	4.00	-25.67	4.70	6.00	57.08
Median	4.20	3.00	-25.00	5.00	6.50	14.87

Wilcoxon Test
(Pre×Post)
	Control	Study
	Calculated T = 9.00	Calculated T = 2.50
	Critical T = 3.00	Critical T = 1.00

Mann – Whitney Test
(D% Control×D% Study)
Calculated U = 16.00	Critical U = 17.00
D% Control < D% Study

4 Discussion

This study showed that the treatment of patients with oligo-, asteno-, terato- and oligoastenoteratozoospermia without apparent cause using acupuncture and moxa techniques can positively influence semen quality, once it improves semen morphology. This result was in accordance with Gerhard et al [5]. The possible mechanism by which acupuncture and moxa improve the sperm morphology may include their possible action through the nervous system. Acupuncture points are areas histologically differentiated, capable of generating an action potential which is conducted by the neural fibers A delta and/or C [11-13]. This stimulus at the posterior column medulla level can create a somatovisceral reflex arc or climb to superior centers, such as the reticular formation, thalamus and cerebral cortex [14, 15]. The response can be probable testicle and epididymis vasodilation. This fact is important when we correlate semen quality and the abnormal presence of reactive oxygen species (ROS). Previous studies have demonstrated that there were lower levels of seminal antioxidant agents in infertile patients, especially in those with compromised sperm motility, than in fertile men [16, 17, 18]. Besides, Gerhard et al [5], Siterman et al [6] and Siterman et al [7] indicated that in the treatment of infertile men with acupuncture, the best results were obtained in those with genital tract inflammation and varicocele, two sources of ROS [19, 20]. Thus, the lipidic peroxidation process in sperm plasma membrane and the high toxicity of the generated fatty acid peroxides proposed as being responsible for the functional and morphological alterations [21], would benefit from the vasodilatation caused by acupuncture and moxa treatments. This vasodilatation would supply antioxidant supplementation as vitamins C and E and glutathione to prevent plasma membrane damage by ROS, thus allowing the gamete recovery [16, 22]. Despite the small number of patients in this study, acupuncture and moxa treatments seem to favorably modify normal-form sperm counting.

In conclusion, the Chinese Traditional Medicine acupuncture and moxa techniques significantly increase the percentage of normal-form sperm in patients with oligoastenoteratozoospermia without apparent cause.

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Correspondence to: Dr. Edson Gurfinkel, R. Urbanizadora, 118 apt. 101, 01252-040 São Paulo, Brazil.
Tel/Fax: +55-11-3032 8348
E-mail: egurfa@uol.com.br
Received 2003-06-16 Accepted 2003-08-06