16 The Treatment of Ovarian Hyperstimulation Syndrome (OHSS) with Acupuncture Journal of Chinese Medicine Number 85 October 2007

The Treatment of Ovarian

Hyperstimulation Syndrome (OHSS) with
Acupuncture in Women Undergoing
Assisted Reproductive Techniques (ART)
By: Naava Abstract
Carman Ovarian Hyperstimulation Syndrome (OHSS) is a potentially serious side-effect of the drugs given during ART
(Assisted Reproductive Technique) treatment. Although the condition occurs in only 3-5% of women undergoing
Keywords: ART, acupuncturists specialising in treating infertility will see it far more often, as the women they treat often fall
OHSS, IVF, into those categories of patient which are susceptible to OHSS. If practitioners can identify the onset of OHSS at
damp-heat, a very early stage, most cases of mild to moderate OHSS can be successfully treated with acupuncture to relieve
PCOS, what may be significant discomfort, to prevent the development of severe OHSS and to allow an embryo transfer
acupuncture, to take place. In severe cases acupuncture can help to alleviate many of the more serious symptoms in conjunction
TCM, ART. with Western medical treatment. If a pregnancy results when the patient is still experiencing OHSS, the pregnancy
hormones will worsen the symptoms. Acupuncture in this case is an invaluable tool to help the patient through what
could otherwise be a very difficult first trimester.

Introduction Women who are already coming to the acupuncture

O
varian Hyperstimulation Syndrome (OHSS)
is a potentially serious side-effect of the
drugs given during ART treatment. Mild
OHSS results in some ovarian enlargement with slight
abdominal pain and swelling and the standard medical
treatment is pain relief. Moderate OHSS results in
more noticeable pain and swelling with nausea and
vomiting. Again, pain relief may be required and the
treatment also includes bed rest. Severe OHSS can
result in the leakage of hormones and uid from both
ovaries and this in turn may cause accumulation of
uid both in the abdominal cavity and in the chest.
Active medical and/or surgical intervention is always
required in severe cases of OHSS. OHSS generally
does not occur until between three and six days
after ovulation, and, ironically, can be heightened by
a pregnancy occurring, the levels of natural human
chorionic gonadotrophins increasing as a result of the
pregnancy. OHSS is more likely in patients with PCOS
(polycystic ovarian syndrome). OHSS can prevent
embryo transfer from taking place.
Acupuncturists are often asked to treat women
undergoing ART, either to prepare them for their
rst attempt, to help improve their reproductive
health following previously unsuccessful cycles or to
treat them during the IVF procedure itself. Research
has shown that acupuncture not only improves the
pregnancy rate after ART,1 but also improves follicle
growth2 and endometrial thickness3. It may also help
resolve any trauma to the ovaries after egg collection,
ensure uterine receptivity during egg transfer and aid
implantation after transfer.
clinic and may be susceptible to OHSS may be treated
preventively, or if they present with the symptoms of
OHSS they can be treated to resolve the condition.
The three major at risk categories in OHSS are:
Women with a history of PCOS.
Women who have failed to respond to fertility
drugs in previous IVF attempts, but whose
reproductive health has subsequently improved
after acupuncture, herbal medicine and nutritional
therapy.
Women who have normal oestrogen levels and
reproductive health but are undergoing IVF due
to the infertility of their partners, usually using the
Intracytoplasmic Sperm Injection (ICSI) procedure.
During IVF the follicles are stimulated to produce
as many eggs as possible. FSH (follicle-stimulating
hormone) is injected at higher doses than the body
would naturally produce and the resultant follicles
can grow up to 20mm in diameter. This process in
itself creates a risk of superovulation, and in women
who have PCOS the risk is far greater as the ovary is
lled with tiny half-ripened or unripe follicles which
all respond to the externally administered FSH.
Although on the surface it would appear benecial
that more follicles give more eggs to choose from, in
reality the follicles are usually of poor quality.
Ovarian Hyperstimulation Syndrome and ART
After multiple ovarian follicles are stimulated and then
identied by ultrasound during an ART procedure,
ovulation is encouraged by administering human
chorionic gonadotrophin (hCG). At this time the
Journal of Chinese Medicine Number 85 October 2007
circulating oestrogen levels are high, leading the ovaries
to enlarge. If the circulating oestrogen continues at a high
level, however, the hormones can leak from the ovaries
into the pelvic cavity. The presence of these hormones
draws uid from the blood, leaving it more concentrated
and prone to clotting. Symptoms usually begin 4-5 days
before egg collection but may appear sooner.4
Complications and risk factors of OHSS
In some cases OHSS may lead to:
Termination of pregnancy.
Blood clotting disorders.
Kidney damage.
Twisted ovary (ovarian torsion) which cuts off its own
blood supply.
Fatality in severe cases which are left untreated.
Women especially at risk of OHSS are those with
polycystic ovarian syndrome (PCOS). One must
remember when treating patients with OHSS who also
have PCOS that the condition will be more stubborn and
difcult to treat than usual. The accumulation of uid is
also more pronounced and entrenched in PCOS patients,
and so more emphasis must be put on resolving it. There
is evidence that adding the drug metformin to ovulation
induction drugs in women with PCOS reduces the risk of
developing OHSS.5 Metformin reduces insulin resistance
which is a major contributing factor in the development
of PCOS.
Young women, who have naturally high hormone levels,
are also at risk, as are women who respond very quickly to
the stimulating drugs and have resultantly high oestrogen
(E2) levels (4,000pg/ml or above) preceding ovulation
induction. Women with more than eight follicles in one
ovary upon ultrasound should be watched closely, as this
is often an early warning signal of OHSS. Finally, using
hCG continuously for luteal phase support can also elevate
the risk, and so if OHSS is suspected, a recommendation
of progesterone for luteal phase support is made instead
of hCG.
It should be noted that at the point where the body
swells up with intraperitoneal uid, or if blood clotting
disorders threaten, the patient must be hospitalised. The
underlying blood stasis in women who also have PCOS
makes this a real possibility and the TCM practitioner
should watch for symptoms such as cramping in the
lower limbs and bruising from the early stages of the
IVF process in these women. Blood clots must not be
treated by acupuncture once they have been suspected or
diagnosed for fear of dislodging them and causing deep
vein thrombosis or pulmonary emboli. However one
or two points to move the blood during menstruation
(natural or articial) at the beginning of the treatment
process are a prudent preventive measure, especially in
patients with PCOS.
The Treatment of Ovarian Hyperstimulation Syndrome (OHSS) with Acupuncture 17
Symptoms of OHSS
OHSS can be broken down into three categories; mild,
moderate and severe.6
Women experiencing mild OHSS may have abdominal
bloating, nausea, diarrhoea, slight weight gain and
enlarged ovaries which are less than 5cm in diameter.
The high levels of oestrodial/E2 and progesterone in the
bloodstream may upset the digestive system and uid
balance, causing the bloating. Patients are advised to avoid
sexual intercourse, avoid pelvic exams other than by one
of the treating fertility physicians, reduce their activities to
avoid any heavy lifting, straining or exercise, drink lots of
clear uids and eat a high protein diet to help metabolise
the drugs.
With moderate OHSS, women can expect a weight
gain greater than 2lbs per day, an increased abdominal
measurement causing clothes to feel tight, vomiting and
diarrhoea, scanty and dark urine and excessive thirst. Their
skin and hair may feel dry and the ovaries may swell to
between 5 and 10cm. The digestive system continues to be
upset, and uid imbalance causes dehydration as well as
severe bloating as body uids collect in the abdomen and
other tissues. Fertility clinics normally advise the patient
to continue the same treatment process as in cases of mild
OHSS, but to be monitored regularly by ultrasound to
check for intraperitoneal uid and ovarian size, and to
record how often urination takes place on a daily basis.
A drop of more than 50% in the frequency of urination,
a weight gain of more than 5 lbs in 24 hours or increased
pelvic pain are all indicators that OHSS is increasing in
severity and that Western medical intervention should be
sought.
Severe OHSS is present when the fullness and bloating
has extended to above the belly button, and is accompanied
by shortness of breath, urine reduction or darkening, calf
and chest pains, lower abdominal pain, stools which are
difcult to pass and uid in the intraperitoneal cavity.
OHSS progresses to this state of severity when the ovaries
have continued to swell, and the lack of uid absorption
causes uid to collect in the lungs and/or abdominal
cavity as well as in tissues, further increasing the risk of
abnormal blood clotting. With severe OHSS the patient
must be hospitalised immediately for observation and
assessment. If uid is found in the abdominal cavity, it
may need to be drained using a syringe.
Patient expectations and management in the treatment
of OHSS
Patients may come to see practitioners at any of the
above stages or, if they are coming for treatment to assist
generally with the IVF process, even before they occur, in
which case the practitioner may be able to prevent OHSS
from developing. In whatever condition that they present
in clinic, however, it is important that patients be given
clear information.
18 The Treatment of Ovarian Hyperstimulation Syndrome (OHSS) with Acupuncture
The rst clinical sign of OHSS I have seen in my clinic
is a dry mouth with little desire to drink and I have
found that in every such case, if untreated, they go
on to develop OHSS. It is the practitioners job at
this point, therefore, to begin daily treatment, and to
monitor blood results closely from the fertility clinic.
Each time the patient is scanned during the IVF
process, the following three results should be brought
to the practitioner to determine whether further
acupuncture treatment is necessary.
Endometrial thickness
Follicle growth and number
Oestrodial/E2 levels
The endometrial thickness determines whether
treatment is needed to tonify or to move qi and blood.
An endometrial thickness of 7 or 8mm is acceptable
for implantation of the egg and a good indication
that progesterone is being excreted as expected.
However during menstruation the endometrium
should be thinner, and if this measurement is more
than 5mm a number of clinics will delay treatment
until it has thinned. This is common in women with
PCOS due to the underlying blood stasis, and at this
stage using points which move qi and blood in the
abdomen (sometimes with mild electro-stimulation)
is appropriate. On the other hand if the endometrium
is not thickening as it should in the follicular phase,
despite proper follicle growth, then moxa should
be applied on the abdominal Conception vessel
points, and blood tonifying points should be used.
If signs of OHSS are perceived symptomatically
at this stage or by looking at oestrodial levels, then
points which combine moving and tonifying such
as Tituo N-CA-4 should be used judiciously and the
thickness monitored daily to determine the response
to acupuncture treatment.
The ovarian response in terms of follicle growth
will help determine whether OHSS is going to be
an issue. Diagnostic signs include many follicles of
fairly uniform size - more than would usually be seen
at this stage - and a slight, abnormal swelling in the
ovaries. This information will come from the patients
feedback from the clinic following scans and blood
tests.
If there are no signs or symptoms of OHSS in the
follicular phase and follicles are not growing as fast
or as numerously as they should be, then moxa cones
on Zigong M-CA-18 as well as stimulation to the ear
ovary points should be applied. If there are signs and
symptoms of OHSS such as a feeling of swelling in
the abdomen, a dry mouth or nausea then no further
stimulation to the ovaries should be given.
The E2 levels are the most important information
needed to determine the onset of OHSS. If the readings
are going up too rapidly (reaching 5000 pg/ml early in
Journal of Chinese Medicine Number 85 October 2007
the cycle) the practitioner must be able to respond with
daily treatments to lower them. Points which tonify,
such as Zigong M-CA-18, Taixi KID-3 or Zusanli ST-36
will raise E2 levels, especially when used with moxa,
so care must be taken not to use these, and rather to
use points which have the opposite effect and either
drain damp, such as Fenglong ST-40, regulate qi,
such as Taichong LIV-3, or clear re, such as Ranggu
KID-2 or Xingjian LIV-2. These must be used with
care, however, to ensure that the endometrium is not
depleted of any necessary thickness. When treating to
lower E2 levels, the patient must report back to the
practitioner the results of any blood tests (which at
this point will probably be done daily) as well as the
subjective reduction of OHSS symptoms, in order to
monitor progress.
With mild OHSS, daily acupuncture treatment
for three days will allow an embryo transfer to take
place 90% of the time and prevent the patient from
developing moderate OHSS. At a moderate level of
OHSS, we have found that four to ve days of daily
treatment will allow a transfer to take place 80% of the
time, and prevent the patient from developing severe
OHSS. If we encounter a case of severe OHSS then
treatment will need to take place daily for a week.
These gures are taken from my own practice, and
as yet I have not treated enough patients with severe
OHSS to form an accurate idea of the success rate.
We can usually halt the progression of OHSS with
acupuncture, but cannot necessarily achieve a positive
pregnancy outcome. We need to be clear with our
patients about this, and also do our best to safeguard
their interests. This is especially so if, as a result of
our treatment, their natural hormone levels have
improved, as it may raise the likelihood of OHSS in
their next IVF cycle. If the patient falls into one of the
three categories of risk listed above, especially the last
in which their hormone levels are likely to be normal,
then extra care must be taken to communicate this to
the fertility clinic.
It should also be ascertained how often the patient
is being monitored, including whether they will be
checked over a weekend. If the E2 levels are high
on a Friday, for example, they should be checked by
the patients IVF clinic again before Monday so that
treatment may be given quickly if OHSS appears.
Sometimes our role as acupuncturists can be more
than merely to provide treatment and a sympathetic
ear; we can act in our patients interests by ensuring
good communication with their fertility clinic.
Aetiology and pathology of OHSS
In the analysis of OHSS according to TCM theory I am
indebted to Steven Claveys book Fluid Pathology
and Physiology in TCM,7 which offers a clear
Journal of Chinese Medicine Number 85 October 2007
explanation of the Sanjiao and the systemic effect of uid
accumulation on the bodys qi.
In general, OHSS can be classied as a damp-heat pattern.
However the practitioner must have an understanding of
the pathologies underlying OHSS and recognise how the
ow of qi is impaired.
Qi deciency and uid accumulation
Qi deciency is one of the main underlying problems in
women with OHSS and especially if they also have PCOS.
The bodys qi is sluggish and already prone to stagnation
of dampness which in itself transforms easily to heat. The
body is therefore unable to metabolise or rid itself of the
effects of the stimulating, heating hormones being injected,
or control the swelling of the ovaries as they fail to absorb
the additional uid. Conversely, uid accumulation
impedes the ow of qi and a vicious cycle is created which
is often enough to initiate OHSS. This is particularly true
of patients who have PCOS. In these women the hallmark
symptom of a dry mouth heralds the rapid onset of OHSS
and treatment must be applied without delay.
Damp-heat
Fluid and heat combine to transform into endogenous
damp-heat, a pathogenic inuence which most of all
affects the Sanjiao. In turn, the Sanjiao loses its spreading
and transforming ability and can no longer function to
open and regulate the uid pathways which send qi down
to the Bladder. Feeling the skin of an OHSS patient is very
useful to determine if damp or heat predominates. If the
patient has cool skin, then damp predominates, and if it
feels hot then heat predominates. Damp-heat obstructing
the qi of the lower jiao can cause the Kidneys to lose their
strength and fail to vaporise and transform uids into
urine or reusable qi, leading to uid retention, scanty
urine, and the seeping out of uid into the skin to cause
oedema. This can easily occur in infertile patients who
often already have underlying Kidney deciency.
Liu Wan-Su (1110-1200) remarks in Su Wen Xuan Ji Yuan
Bing Shi (Examination of the Original Patterns of Disease
from Mysterious Mechanisms of the Su Wen): When
damp and heat struggle, the struggle leads to obstruction,
the obstruction disturbs normal urination, and there will
be edema.8
The Sanjiao is the road of water and foods, the beginning
and the end of qi. (31st Difculty Nan Jing).9 It links yin deciency. Cycles previously controlled via the
the Lung, Stomach, Spleen, Small Intestine and Large
Intestine, drains into the Bladder and has an internal/
external relationship with the Pericardium and therefore
the Heart. The surface tissues are where the Sanjiao
moves and gathers qi. It then distributes yuan qi from the
Kidney and acts as a pathway for transformed uids. It
drains murky uids from the body into the Bladder and
reabsorbs clear uid qi back into the body. So the Sanjiao
must be a clear pathway to enable Heart yang to descend
The Treatment of Ovarian Hyperstimulation Syndrome (OHSS) with Acupuncture 19
and warm Kidney yang, and for Kidney yin to rise and
nourish Heart yin.
When damp-heat affects the movement of qi through
the Sanjiao, clear yang cannot rise nor turbid yin descend,
causing them to intermix and substantially obstruct the
ow of qi. This will cause chest obstruction, shortness of
breath and abdominal distension which sinks downward
towards the lower jiao because of the heavy nature of
damp. Su Wen Chapter 2, states: Turbid qi above will
then produce distension.10
Damp-heat also commonly affects the function of the
Spleen and Stomach, causing vomiting and diarrhoea.
It interferes with the Spleens ability to raise and the
Stomachs ability to descend. The patient will not feel
like eating (which it is important to do, nevertheless, as
a high protein diet will help the body to metabolise the
drugs and clear the OHSS) so the vomiting will more
often than not come from an empty stomach, will be more
like bile and will display itself in thin streams. If there is
dry retching on the other hand accompanied by a glossy
mirror-like tongue, then the damp-heat has produced
re which has injured the Stomach uids. Damp in the
stools manifests as diarrhoea with mucus and a sensation
of incompleteness on defecation. According to Steven
Clavey, since heat dries damp while damp clutches at
heat, there may also be gluey, tar-like, sticky stools which
are hard to pass.11
Thirst, the hallmark sign of the onset of OHSS, can
also be attributed to the accumulation of damp-heat.
Damp obstructs the rise of normal jin and ye uids so
they cannot moisten the throat and mouth. In clinic one
can easily see whether damp or heat predominates by
assessing the degree of thirst. Great thirst is treated with
heat clearing points such as Neiting ST-44, whereas lesser
thirst indicates that damp predominates and points such
as Yinlingquan SP-9 are emphasised.
Finally, in cases of severe OHSS, damp-heat may sink
down to the legs. The accumulated oedema and heat
obstruct the qi in the channels giving rise to calf pain.
Heat injures jin and ye uids
As stated above, exogenous heat enters the body in the form
of the FSH and hCG injections. If there is an underlying
yang deciency the heat may not manifest signicantly,
however it will be exacerbated by any underlying Kidney
contraceptive pill may cause Liver qi stagnation which
also easily turns to heat.
Heat injures jin and ye uids. Jin uids are watery and
clear, ow quickly and easily and their pathway ows
through the Sanjiao,12 while ye uids ow through the
zangfu, bones and joints. If the jin uids are injured by
heat they form a pathological accumulation of water, damp
and phlegm. This impairs the ow of qi and eventually
damages ye uids and zangfu function.
20 The Treatment of Ovarian Hyperstimulation Syndrome (OHSS) with Acupuncture
Shen disturbance
If not already affected by the stressful process of ART, the
shen may also be disturbed by pathological changes in the
uid metabolism.
Both jin and ye uids are needed to form the qi and blood
which is the material basis of shen. Chapter 9 of Su Wen
says: Jin and ye uids must complement each other, and
then shen will manifest on its own.13 If the uids are injured
there may be palpitations, anxiety, shortness of breath, chest
oppression, and disturbance of qi movement through the
Penetrating (Chong) vessel as it passes through the chest.
In this situation one may calm the mind by regulating the
Sanjiao and transforming the accumulated uids.
It should be stressed that the shen is the one element
which must be treated in all cases of OHSS, however mild
or severe. IVF is an arduous process both physically and
emotionally and the additional physical strain of OHSS
coupled with uncertainty as to whether a transfer will go
ahead places women under considerable emotional stress.
It is always benecial for ongoing support to add ear seeds
or press needles at Ear Shenmen and Kidney for calming
the spirit.
Tongue and pulse diagnosis in the treatment of OHSS
The tongue varies depending on whether damp or heat
predominates, so close attention should be paid at every
treatment. It may even change within a single treatment so
that a mirror-like coating at the beginning may change to
the beginnings of a sticky coating at the end. This indicates
that the heat has cleared and damp now rises to the surface
to predominate.
The key features of tongue diagnosis are as follows:
If the coating is white, damp predominates.
If the coating is yellow, heat predominates.
If it is yellow, thick, greasy and sticky, heat overrules
damp with a tendency to phlegm.
If it is yellow, thick and dry, the heat is stronger than the
damp and there is a tendency to re.
If it is overlaid by sticky murky uids, damp obstructs
the Spleens transformation of uids.
If it is yellow, slippery and moist like raw egg yolks,
damp-heat predominates with water failing to be
transformed and becoming turbid and pathogenic.
If it is darkish yellow, thick and murky, turbid pathogens
and damp-heat have invaded the interior.
The coating seen in OHSS can be differentiated from
that produced by externally administered progesterone
(Cyclogest) in the luteal phase by its sticky or slippery
quality. The coating produced by the progesterone is
usually yellow and characterised by a dry quality.
The pulse may be non-specic (the battle between damp
and heat in the body can give rise to a variety of pulses,
including wiry, slippery and decient). Generally, however,
if it is oating or thready then damp predominates and if
rapid, heat predominates.
Journal of Chinese Medicine Number 85 October 2007
TCM Treatment of OHSS
To successfully treat OHSS, the practitioner must strike
a balance between nourishing and regulating, tonifying
and reducing. Treatment must be applied on a daily basis
and accompanied by advice to drink a lot of water and
eat a protein-rich diet in order to improve the bodys
metabolism of the drugs. Nourishing points are those
which will thicken the endometrium while not exacerbating
the OHSS, for example blood tonifying points which
also have a slightly damp-heat clearing action such as
Ququan LIV-8. Regulating points such as Taichong LIV-3
encourage the qi to move without an overtly clearing or
tonifying effect. Tonifying points such as Zigong M-CA-18
or Taixi KID-3 strengthen the qi of the body but should
only be used sparingly when someone is suffering from
OHSS, otherwise the condition could be exacerbated. It is
therefore important to distinguish whether the symptoms
the patient is displaying, such as fatigue, come from
deciency or from excess. Finally, reducing points should
also be used sparingly, as although they will act to lessen
the OHSS symptoms (particularly those which involve
heat) they may also drain the qi.
Basic prescription for the symptomatic treatment of
OHSS, whether mild or severe
Yingu KID-10 clears damp-heat from the lower jiao and
benets the Kidneys.
Tianjing SJ-10 calms the spirit, descends rebellion and
clears heat from the Sanjiao channel.
Zusanli ST-36 harmonises the Stomach, tonies the qi
and calms the spirit.
Taibai SP-3 tonies the Spleen, resolves damp-heat, and
regulates and harmonises the Spleen and Stomach.
Yintang M-HN-3 calms the spirit.
Tituo N-CA-4 raises and regulates the qi in the uterus.
Ligou LIV-5 clears damp and heat from the lower jiao.
Tianshu ST-25 regulates the Spleen, Stomach and
intestines, resolves damp and damp-heat, regulates the qi
and blood and eliminates stagnation.
Dabao SP-21 regulates qi and blood and unbinds the
chest.
Xuehai SP-10 moves the blood and lessens the risk of
clotting.
This point prescription covers all aspects of OHSS. It
tonies the qi without making the OHSS worse, resolves the
damp and damp-heat without thinning the endometrium,
and clears heat without draining the qi. Xuehai SP-10 is
added in a preventive capacity. However in order that
the root of the condition is addressed, the prescription
should always be adapted using some of the following
points chosen according to pattern differentiation and the
patients condition.
Journal of Chinese Medicine Number 85 October 2007
Treatment according to pattern differentiation
Damp
Treatment principle: resolve damp
Yinlingquan SP-9 resolves damp, strengthens the Spleen
and opens the water passages.
Pishu BL-20 tonies the Spleen qi, resolves damp and
regulates and harmonises the middle jiao.
Zhongwan REN-12 and Qihai REN-6 restore the
function of the Stomach and intestines to resolve damp
and strengthen the yuan qi to act upon damp.
Dazhui DU-14 promotes the ow of yang qi and pushes
residual damp out of the body through the surface tissues.
This point is very powerful in combination with any of the
other points and must be combined with a tonifying point
such as Taixi KID-3 so as to prevent excessive draining of
the qi.
Daimai GB-26 regulates the Girdling (Dai) vessel and
drains damp.
Shuifen REN-9 regulates the water passages to treat
oedema and dispels accumulation.
These points resolve damp to reduce bloating and also
the size of the ovaries which have been swollen by excess
uid. They may also help reduce shortness of breath,
oedema and abdominal and calf pain. Points used to
reduce are combined with ones that tonify in a 2:1 ratio so
as to avoid the qi being overly drained.
Damp-heat
Treatment principle: drain damp and clear heat.
The following points act upon all three jiao:
Neiting ST-44 harmonises the intestines and clears
damp-heat.
Neiguan P-6 promotes the smooth ow of qi and unbinds
the chest, clears heat, calms the spirit, and harmonises the
Stomach to relieve nausea and vomiting.
Zhigou SJ-6 regulates qi and clears heat in the three jiao,
moves the stool and benets the chest.
Hegu L.I.-4 promotes the smooth ow of qi.
To act upon the middle jiao:
Zhongwan REN-12 tonies the qi of the middle jiao to
support the elimination of damp.
Zhigou SJ-6 as above.
Zusanli ST-36 harmonises the Stomach and tonies qi to
remove damp.
Pangguangshu BL-28 drains damp-heat by facilitating
urination.
Daimai GB-26 regulates the Girdling vessel and drains
damp.
To act upon the lower jjao:
Ligou LIV-5 drains damp and clears heat from the lower
jiao.
Shuidao ST-28 regulates the lower jiao, benets the
Bladder and dispels stagnation.
The Treatment of Ovarian Hyperstimulation Syndrome (OHSS) with Acupuncture 21
Pangguangshu BL-28 as above (acts particularly on the
lower jiao).
This is a very important group of points when treating
OHSS, as the main component in any diagnosis of
OHSS is damp-heat. As with points which drain damp,
however, they must be balanced with tonifying points,
in this situation in a ratio of 3 or 4:1. They are powerful
points and are best used in a group of three or more when
treating moderate or severe OHSS. When the OHSS is still
mild then two or three points are appropriate, together
with a point or two to regulate or tonify.
These points may also be applied according to which
of the jiao they affect. As OHSS becomes more severe, the
uid will spread from the lower to the upper jiao, and
points can then be selected according to which part of the
body is most in need of support.
Stagnation in the channels of the lower limbs
Treatment principle: Move stagnation and smooth qi in
the channels
Huantiao GB-30 restores qi and blood circulation to the
legs.
Yanglingquan GB-34, hui-meeting point for tendons,
promotes the ow of qi locally.
Xuanzhong GB-39, hui-meeting point for marrow,
tonies the Kidney and eliminates wind.
Qiuxu GB-40 clears Liver and Gall Bladder heat and
damp-heat.
These points are used if OHSS begins to affect the lower
limbs, causing cramping with oedema.
To treat damp-heat with underlying PCOS
Treatment principle: Drain damp-heat and regulate qi
Geshu BL-17, hui meeting point for blood, invigorates
the blood and harmonises the diaphragm and Stomach in
order to resolve damp.
Ganshu BL-18 regulates the Liver.
Jianshi P-5 transforms phlegm, regulates the Stomach to
remove damp and descends rebellious Stomach qi. Used
especially with Fenglong ST-40.
Fenglong ST-40, a major point to resolve phlegm and
damp, clears phlegm from the Heart and calms the spirit.
Zulinqi GB-41 resolves damp-heat and regulates the
Liver.
Taichong LIV-3 regulates the Liver and the lower jiao.
Used with Zulinqi GB-41 to clear damp-heat.
Ququan LIV-8 clears damp-heat from the lower jiao,
invigorates the blood, benets the uterus and nourishes
the blood and yin.
OHSS with underlying PCOS is much harder to treat
than OHSS by itself as there is already a background of
both damp accumulation and qi deciency. More bloating
and distension will be seen as soon as IVF treatment starts
and therefore the priority with the rst treatment or two
is to clear the symptoms, primarily using points which
22 The Treatment of Ovarian Hyperstimulation Syndrome (OHSS) with Acupuncture
drain and only one or two points which tonify. However
tempting it may be, if one tonies the qi too quickly the
symptoms will become much worse.
The treatment of OHSS during pregnancy
Once the embryo transfer has been accomplished,
treatment must be given with care, since most of the
points given above have a draining action or are used
with reducing method, both of which are contraindicated
in pregnancy. However the situation often requires
intervention as pregnancy may cause a worsening or
persistence of symptoms because of the increasing levels
of circulating hormones.
In treatment it is most important to consider the level
of qi deciency which predated the IVF process. Even
in qi decient patients the qi is mainly supported by
regulating it, rather than directly tonifying, using points
such as Ququan LIV-8 and Jianshi P-5. If the patients
own qi is strong and she is having IVF due to male factor
infertility, for example, then a few more points such as
Zhigou SJ-6, Zhongwan REN-12 and Tianshu ST-25 can
be added. Treatment which has an overall tonifying effect
only worsens the symptoms. On the other hand no more
than two points which are draining should be added to
the prescription unless the OHSS is severe and worsening.
Points to clear the symptoms of OHSS are also carefully
targeted to the upper and middle jiao.
If the patient has PCOS as well as OHSS in pregnancy
the symptoms will often be very severe. The patient is
often hospitalised at this point or at the least constantly
monitored. The priority here is to use points around the
midline such as Daimai GB-26 and Tianshu ST-25 in order
to relieve the pressure and discomfort in the abdomen,
coupled with points to calm the mind and only one point
such as Taixi KID-3 to strengthen the Kidney. Although
only a few points should be used in pregnancy they can
still be extremely effective in this situation.
Discussion
One can measure success in treating OHSS in three ways:
Reduction or cessation of symptoms.
The ability of an egg transfer to go ahead.
Pregnancy.
While OHSS reduces the chances of pregnancy, if
treatment is applied correctly we can certainly expect to
see a reduction or cessation of symptoms. Furthermore, in
about 75% of cases of mild to moderate OHSS the embryo
transfer will go ahead.
If the fertility problem lies with the husband the
prognosis is better again. The body is not disadvantaged by
underlying qi deciency or damp stagnation. In 85-90% of
cases when there is nothing wrong with the female partner
an embryo transfer will go ahead, even in the more severe
cases. In cases of PCOS when the symptoms of oedema,
shortness of breath and abdominal distension are severe, it
Journal of Chinese Medicine Number 85 October 2007
may be useful to add herbal formulae in tablet, decoction
or tincture form. In conditions where heat predominates
over damp and there is excessive thirst, one can even use
decocted herbs frozen into ice cubes and sucked one at
a time without fear of exacerbating the damp. It should
be noted, however, that while adding herbs may increase
effectiveness in this situation, it is unfortunately beyond
the scope of this article to discuss herbal treatment.
Case history moderate OHSS
Background
Patient B, aged 32 years, came to see me after one failed
IVF (ICSI) attempt. There was no Western medical
diagnosis which would necessitate ART but her husband
had azoospermia and I also felt that she would benet
from treatment. Her signs and symptoms were as follows:
occasional mouth ulcers, slight thirst, restless legs and
sleep with vivid dreams and palpitations. She had a
tendency to bruise easily and had a thin whitish-yellow
vaginal discharge for most of the cycle. She suffered PMS
with breast tenderness, backache in the early evening,
abdominal bloating and night sweats, and her cycle was
generally 33-34 days long, with a slightly lengthened
follicular phase. The period began with a mucousy,
bloody discharge, followed by purple/red, scanty
bleeding with large clots. Her tongue was purple/red,
swollen, dry and without a coating and her pulse was
wiry, rapid and very decient at the Kidney yin position.
I diagnosed Kidney yin deciency with heat affecting
the Heart, Spleen deciency with damp in the lower jiao,
Liver qi stagnation and blood stasis. I treated her once
a week, and then as she made progress, on weeks one
and four of her menstrual cycle, using acupuncture to
strengthen the Spleen, regulate the qi and promote blood
circulation to resolve blood stasis, and Chinese herbs to
nourish the underlying Kidney yin deciency and resolve
the damp. After three months her symptoms had largely
resolved and we decided she should attempt another
IVF cycle. I advised the clinic that she would probably
have an increased level of responsiveness to the fertility
drugs.
OHSS
Once the IVF cycle started, B. came to see me only twice,
as in contrast to her rst IVF cycle she was responding
well. The follicles were growing, the endometrium was
thickening well, and the E2 levels appeared to be under
control. I treated her for some fatigue while she was
using the stimulating medication and then again for a
headache toward the end of the period of stimulation.
However two days before she was due to take the HSG
trigger for ovulation her E2 levels rose dramatically to
just under 5,000 pmol/L and we suspected she was being
hyperstimulated. This was denied by the clinic until at egg
collection when her ovaries were seen to be very swollen.
Journal of Chinese Medicine Number 85 October 2007
Signs and symptoms
bloating
thirst
dark urine with a sensation of heat
nausea
swollen ovaries
The clinic expressed doubt that the embryo transfer
could take place.
TCM pattern differentiation
B.s background history of Spleen qi deciency and
damp in the lower jiao, in addition to the exogenous
heat from the medication, predisposed her to damp-
heat. The damp-heat in turn affected the function of the
Sanjiao, and palpation of her skin established that the
surface tissues in which the Sanjiao moves and gathers
qi had become waterlogged. My ngers sank into the
esh on the patients middle and lower abdomen,
and the cool temperature of the esh showed me that
at this point damp was predominating over heat,
although the slightly darkened urine was evidence
that there was also heat. Her tongue was red with a
pale yellow, slippery and wet coating and her pulse
was rapid and soggy. My diagnosis was therefore
of damp-heat in the middle and lower jiao affecting
the smooth function of the Sanjiao, with underlying
Spleen qi deciency.
Treatment
As we had three days to wait before the embryo
transfer, this was an ideal time to work on clearing
the damp-heat without worrying about whether she
was pregnant. In addition, we needed to maintain the
thickness of the endometrium despite the dispersing
nature of the treatment. This would be continually
checked by the clinic prior to transfer, so if it was
reduced we planned to offer herbs or acupuncture to
support its growth.
I treated B. daily for the three days before her embryo
transfer using the treatment principle of resolving
The Treatment of Ovarian Hyperstimulation Syndrome (OHSS) with Acupuncture 23
damp-heat in the middle and lower jiao, moving qi in Figs 1-3: (L-R)
the Sanjiao and strengthening the Spleen. Examples of
mild, moderate
Day 1 and severe
Zusanli ST-36 to harmonise and tonify qi, yin and OHSS
blood, reinforcing method.
Yinlingquan SP-9 to resolve damp, strengthen the
Spleen and open the water passages, reinforcing
method.
Zhongwan REN-12 to strengthen and harmonise
the middle jiao and regulate qi, even method.
Tianjing SJ-10 to calm the spirit, regulate qi, descend
rebellious qi and clear heat from the Sanjiao channel,
reducing method.
Tituo N-CA-4 to raise and regulates the qi in the
uterus, even method.
The rst three points were designed to resolve the
damp and support the Spleen. Zhongwan REN-12 was
used primarily for harmonising the middle jiao and
subduing nausea. Tianjing SJ-10 regulated the qi of
the waterways and its moving properties allowed the
heat to be dispersed without draining. Tituo N-CA-4
has both a moving and tonifying effect which helped
to maintain the thickness of the endometrium while
continuing to move the qi and dispel the bloating.
B. reported that after this treatment the nausea
subsided, her thirst had normalised and the bloating
was slightly better. She slept well and woke feeling
much more positive.
Day 2
Tianshu ST-25, front-mu point of the Large Intestine,
to regulate and resolve damp-heat in the intestines,
regulate the Spleen and Stomach, regulate qi and
blood and eliminate stagnation, even method.
Shuifen REN-9 to regulate the water passages to
treat oedema and dispel accumulation, reducing
method.
Tianjing SJ-10 as above.
Ququan LIV-8 to clear damp-heat from lower jiao,
24 The Treatment of Ovarian Hyperstimulation Syndrome (OHSS) with Acupuncture Journal of Chinese Medicine Number 85 October 2007

invigorate blood, benet the uterus and nourish blood The day after this treatment the embryo transfer took
and yin, reducing method. place without complications, the bloating was almost
Taixi KID-3 to nourish Kidney yin and clear deciency entirely resolved and the endometrium had maintained a
heat, tonifying method. thickness of 13mm.
This was a stronger treatment, as the patient had
responded very well to the rst one. The tongue coating Conclusion
had changed to become dry and yellow and the pulse was Prompt treatment when the rst signs of OHSS were
rapid and slightly slippery. While the previous treatment noticed was very important in this case. We were able to
focused primarily on resolving damp, this treatment reverse the OHSS and the embryo transfer was able to take
needed to focus more strongly on clearing heat and place. The balance of tonifying, draining and regulating
preventing the OHSS from getting worse and affecting the points enabled the thickness of the endometrium to
bowels. Shuifen REN-9 and Tianshu ST-25 resolved damp- remain undisturbed. B. did not become pregnant in this
heat while regulating the intestines, while Tianjing SJ-10 cycle, however. In my opinion this was in part due to
cleared heat and continued to facilitate the movement of the emotional strain of the last minute onset of OHSS,
qi. Ququan LIV-8 cleared damp-heat, but was also used together with the stress of not being listened to by the
for its qi and blood nourishing qualities to maintain the fertility clinic. For her next IVF cycle she transferred to a
endometrium. Taixi KID-3 was used primarily to tonify fertility clinic which paid attention to our warnings over
the Kidney yin and balance the clearing nature of the OHSS and was successful in conceiving and carrying to
other points. term a healthy baby girl.
B. reported that after this treatment the sensation of
heat on urination had gone and the urine had reverted Naava Carman is a fertility and obstetric acupuncturist and
to a pale yellow colour which was more consistent with herbalist. She runs The Fertility Support Company which has
clinics all over London and has recently joined Hammersmith
the amount of water she was drinking. At my suggestion,
IVF with a division of this company to create a fully integrated
she also switched from milk to protein shakes mixed with
private IVF and Acupuncture unit. She is a member of the
water so that the same amount of protein was ingested Federation of Antenatal Teachers, and is a Recognised Birth Doula.
but without the addition of the copious amounts of dairy http://www.thefertilitysupportcompany.co.uk.
product. Her bloating was also noticeably less.
Footnotes producing the chemicals which
cause OHSS, by removing them
Day 3 1 Paulus, Wolfgang. (April 2002). the risk of OHSS is dramatically
Zusanli ST-36 as above. Influence of Acupuncture reduced. This method has
Yinlingquan SP-9 as above. on the pregnancy rate in not yet been introduced into
patients who undergo assisted European ART clinics as far as
Zhongwan REN-12 as above reproductive therapy, Fertility I am aware. Dr Malpani. (2007).
Qihai REN-6, with one cone of Japanese smokeless and Sterility, Vol.77. Ovarian Hyperstimulation
moxa, to restore the qi of the Stomach and intestines to 2 Emmons Sandra et al. Syndrome. Retrieved February
Acupuncture Treatment For 2nd 2007 from: http://www.
support the elimination of damp and strengthens the yuan Infertile Women Undergoing drmalp ani.com/ o v a r i a n -
qi to help resolve damp, tonifying method. Intracytoplasmic Sperm hyperstimulation-syndrome.
Zhaohai KID-6 to nourish the Kidneys, regulate the Yin injection. Medical Acupuncture, htm
A Journal For Physicians By 5 Tang, Thomas. (2006). The
Motility (Yin Qiao) vessel, calm the spirit and regulate the Physicians. Spring / Summer use of metformin for women
lower jiao. 2000- Volume 12 / Number with PCOS undergoing IVF
2 "Aurum Nostrum Non Est treatment, Oxford Journals
Neiguan P-6 to regulate the qi and calm the spirit, even Aurum Vulgi" of Human Reproduction, Vol
method. 3 Westergaard LG, Mao Q, 21(6),1416-142.
Zhigou SJ-6 to regulate the qi, clear heat in the Sanjiao Krogslund M, Sandrini S, Lenz 6 Schenker, JG and Weinstein,
S, Grinsted J. Acupuncture on
and move the stool to eliminate heat, reducing method. D.(1978).Ovarian
the day of embryo transfer Hyperstimulation Syndrome:
The aim of this treatment was mainly to tonify, as the significantly improves the a current survey, Fertility and
bloating was now almost resolved and no other OHSS reproductive outcome in Sterility, Vol 30, 255-268.
infertile women: a prospective,
symptoms remained evident. The tongue coating was now randomized trial: Fertil Steril. 7 Clavey, Steven. (2003) Fluid
yellow in patches and dry and the pulse was rapid and 2006 May;85(5):1341-6 Physiology and Pathology in
Traditional Chinese Medicine.
thin. Points such as Zhongwan REN-12, Yinlingquan SP-9 4 Doctors in India have developed Churchill Livingstone:
an interesting method of helping
and Zhigou SJ-6 continued to clear damp and heat and London.
to avoid OHSS with a special
Neiguan P-6 was used to calm the spirit, as the uncertainty technique applied during egg 8 Ibid p.410.

over whether the eggs would be transferred was causing collection. A double lumen 9 Ibid p.409
needle allows them to remove 10 Ibid p.416
the patient considerable anxiety. The remaining points all the granulosa cells from
11 Ibid p.41
were used to strengthen the body condition and thicken each follicle at the time of egg
retrieval, ushing each follicle 12 Ibid p.17
the endometrium (particularly with moxa on Qihai
meticulously. Since these cells 13 Ibid p.26
REN-6). are the ones responsible for