Infertility for three years

RECORD OF FIRST VISIT

Date of First Visit: 22nd Sep 2008	Name:
Date of Birth: 36 yrs		Gender: Male
CHIEF COMPLAINTS : Infertility for three years
DESCRIPTIONS (4 diagnostic methods)
A) Asking
Present illness history: The patient is married for 6 years. The patient and his partner would like to have children. They started to make children three years ago, but the patient hasn’t felt like to have sex since he was around 33 years old. Recently he finally went to a hospital and he was told that his testosterone level was low. So, now he is on a replacement testosterone therapy by taking injectable depots. His sperm’s quality is normal and not sticky. His sexual activity had been normal until 3, 4 years ago. His weight is 80 Kg and it is BMI 30.9 and obesity. He says His diet is normal, but he eats everything on a plate. He is not working and he stays home for the last half a year. Before the time, he worked as a carpenter and his weight was 75 Kg. His weight had been around 70 to 75 since he was around 20 years old. He plays tennis three times a week. One week ago he injured his left Achilles tendon by tennis. It is not serious but it is sore. He also has been suffering from lower back pain for the last couple of years. The pain is a dull pain. He drinks alcohol once a week. His defecation is normal and constant. The urination is normal and no night time urination. He sleeps seven hours a day and no dreams. He worries about his situation because he is out of work. He doesn’t drink fluid much. He drinks both warm and cold. He drinks milk 200ml a day. He has no cold limbs. He has allergic sinusitis? His nose’s membrane is so weak that he gets bleeding easily, for example, he gets bleeding by washing his face, and sometimes it doesn’t stop for a week to a month. The bleeding symptom started when he was around 20 years old. He has an atopic like skin dermatitis on his legs. It is red and partly dry. He immigrated to New Zealand five years ago.
Past illness history: He has been suffuring from Sinusitis, over weight, atopic like skin dermatitis
Life style: Staying home, not stressful, but has little worry
Family history: Mother; lymph cancer, Father; hepatitis B
Menstruation, marital & obstetrical history : Married for 6 years
B) Inspection
Healthy solid built BMI; 30.9 Tongue; Slightly small and thin tongue body, little pale, crack in middle, with little partly yellowish dry white thin coating
C) Auscultation / Olfaction
Sound : Nothing Abnormal Detected Odors : Nothing Abnormal Detected
D) Palpation
Pulse; Deep and feeble
E) Physical Examination
Whole body is muscular and tight
The result from Western Medicine doctor on 24 Oct 2008; Diagnosis; Severe isolated secondary hypogonadism for 3-5 years 性腺机能减退; 生殖官能不良 Plan; 1, Continue Sustanon 200-250mg IM fortnightly. If injections seem unhelpful he could switch to a trial of Androderm patches 2x2.5mg daily. Sexual related and fertility problems discussed. Results; Normal pituitary MRI, a semen analysis which has shown a normal sperm counter but a borderline motility at 40 % on the 4 June 2008, but persistent low serum testosterone levels of 2.4-4.0. Initial experience with the Sustanon injections suggested that there was improvement for the first week following the injections but a subsequent fall off and hence the switch from 3 weekly to fortnightly injections. The situation has been compounded by endometriosis in his partner, which she had apparently laposcopic surgery at the end of August. As a result He has been off his injections over the past 6 weeks and today’s test reconfirms secondary hypogonadism (Te 4.6, LH 1.4, FSH2.7). His initial presenting symptom was of reduced libido and otency and In general the 2-3 weekly injections should be the most appropriate treatment but if that is not the case and / or he does not like the injections, you could try the androderm patches as suggested. (Through the skin) The result from Western Medicine doctor on 22 May 2008; Diagnosis; Severe isolated secondary hypogonadism for 3-5 years 性腺机能减退; 生殖官能不良 Plan; 1, Further screen for hypopituitarism 垂体机能减退; 垂体机能减退症 2, MRI requested. 3, Sustanon 250mg IM 3 weekly with follow up injections through the nurse here until couple obtain a GP, then transfer 4, semen analysis and assessment regarding primary infertility later

CASE SUMMARY

DIAGNOSIS

A) Diagnosis: Yinwei

B) Syndrome Differentiation : Decline of mingmen fire and damp heat retention underlining Kidney

C) Explanation

Without any reason as western medicine doctor commented, He is suffering from reduced testosterone, and it is causing erectile dysfunction. He has been always big and over weighted for more than 15 years. After he immigrated to New Zealand five years ago, he started to eat more. He likes sweets and takeaway foods. For the last half a year, He has stayed at home and hasn’t been doing much, so his weight has gone up to 80kg. It is BMI 30.9. In TCM, the damp-heat is one of the factors of erectile dysfunction. The damp heat is usually caused by indulge of greasy food diets which damage the function of spleen and stomach causing dampness and it turns to heat. The obesity may be the trigger for his erectile dysfunction. The heat travels down to penis to unable to erect. He is obesity and his body has dampness retention for many years, therefore he may have been suffering from the erectile dysfunction. He also worries about his situation and future. He feels pressure to have children, which may damage his mind and leading kidney deficiency. His pulse is so week and deep, also he suffers from lower back pain, hence, his condition may be more likely to be differentiated to “the declined of mingmen fire” in this present. Yinwei refers to weak erection of penis, in TCM. And they have two causes, one is “Downward flowing of Damp-heat” and another one is by “the declined of mingmen fire”.

TREATMENTS First visit He has never tried acupuncture before; I tried simple points to tonify his kidney and Chensan for his injury.

A) Treatment Principles Tonify Kidney (reduce Damp-heat)

B) Treatment Methods

1. Needling Explanations :

Shenshu, Xiliao, Taixi, Mingmen, Chensan

Shenshu for tonifying kidney, Xiliao for lumber pain and infertility, Taixi is for tonifying kidney yin and yang and lumbago, Mingmen is for benefit for lumbago, Chensan is for his Achilles tendon injury

6. Life Style Advice

Try to avoid greasy oily food, avoid alcohol. They accumulate dampness in the stomach and impair the spleen function. Try to do regular exercise to lose weight.

Yinwei-Male Infertility

DEFINITION ETIOLOGY AND PATHOLOGY DIFFERENTIATION AND TREATMENTS

In TCM, Yinwei is refer to weak erection and erectile dysfunction. They can be differentiated to [Decline of mingmen fire] and [Downward flowing of damp heat]. Decline of mingmen fire; The primary factor is kidney essence deficiency. Usually excessive sex or masturbation are the trigger of Mingmen fire decline. They consume kidney essence. Impotence may come from emotional stress; fear, freight or worry. They also consume kidney essence. Some cases, internal organ’s injuries which were caused by over indulgence of sexual intercourse are the factor. [Downward flowing of damp heat] The damage to the spleen stomach by indulge of greasy food and drinks makes damp-heat in the stomach. The damp-heat travels down to oenis to unable to erect, as a result, impotence occurs. Treatment for [Decline of mingmen fire] Manifestation; Failure or weakness of erection, cold limbs, soreness and weakness of the loins and knees, pale tongue with white coating, deep pulse, palpitation and insomnia, in case of disorder of heart and spleen. Treatment principle; Tonify kidney yang. Selection of points; Mingmen, Guanyuan, Shenshu, Taixi, Treatment for [Downward flowing of damp heat] Manifestation; erectile dysfunction, thirst, better taste in month, hot and dark urine, soreness and weakness of the lowerlimbs, yellow sticky tongue coating, soft and rapid pulse Treatment; Eliminate damp-heat Selection of points; Zhonji, sanyinjiao, yinlinngquan, zusanli

In WMS refer to Wikipedia Erectile dysfunction (ED or (male) impotence) is a sexual dysfunction characterized by the inability to develop or maintain an erection of the penis sufficient for satisfactory sexual performance. An erection occurs due to hydraulic effects due to blood entering and being retained in sponge-like bodies inside the penis. During intercourse, the process is initiated when sexual arousal is transmitted from the brain to nerves in the pelvis. There are various and often multiple underlying causes, some of which are treatable medical conditions. The most important organic causes are cardiovascular disease and diabetes, neurological problems (for example, trauma from prostatectomy surgery), hormonal insufficiencies (hypogonadism) and drug side effects. It is important to realize that erectile dysfunction can signal underlying risk for cardiovascular disease.There is often a contributing and complicating and sometimes a primary psychological or relational problem. Psychological impotence is where erection or penetration fails due to thoughts or feelings (psychological reasons) rather than physical impossibility Causes *Neurogenic Disorders (spinal cord and brain injuries, nerve disorders such as Parkinson's disease, Alzheimer's disease, multiple sclerosis, and stroke.) *Hormonal Disorders (pituitary gland tumor; low level of the hormone testosterone). *Arterial Disorders (peripheral vascular disease, hypertension; reduced blood flow to the penis). *Cavernosal Disorders (Peyronie's disease.) *Nonphysical causes: Mental disorders (clinical depression, schizophrenia, substance abuse, panic disorder, generalized anxiety disorder, personality disorders or traits.), psychological problems, negative feelings. *Surgery (radiation therapy, surgery of the colon, prostate, bladder, or rectum may damage the nerves and blood vessels involved in erection. Prostate and bladder cancer surgery often require removing tissue and nerves surrounding a tumor, which increases the risk for impotence.) *Aging. Lifestyle: alcohol and drugs, obesity, cigarette smoking (Incidence of impotence is approximately 85 percent higher in male smokers compared to non-smokers. Smoking is a key cause of erectile dysfunction. Smoking causes impotence because it promotes arterial narrowing. See also Tobacco and health. ) *Other disorders. Treatment Treatment depends on the cause. Testosterone supplements may be used for cases due to hormonal deficiency. However, the cause is more usually lack of adequate penile blood supply as a result of damage to inner walls of blood vessels. This damage is more frequent in older men, and often associated with disease, in particular diabetes. Treatments (with the exception of testosterone supplementation, where effective) work on a temporary basis: they enable an erection to be attained and maintained long enough for intercourse, but do not permanently improve the underlying condition. There are different treatments available. *Oral treatment 3 different tablets are currently available from the doctor and these work when there is sexual stimulation. Depending on the treatment, it will need to be taken 20 minutes to 1 hour before sex and the period of time over which it works can vary between 3 hours and up to 36 hours. *Alprostadil (prostaglandin) This can be injected into the penis or inserted using a special applicator - usually just before sexual intercourse. Alprostadil has also bcome available in some countries as a topical cream (under the brand name Befar),[23] and preliminary studies have shown a clinical efficacy of up to 83%. It has an onset of action of 10-15 minutes and its effects can last over 4 hours.[citation needed] *Vacuum device Please see main article penis pump These work by placing the penis in a vacuum cylinder device. The device helps draw blood into the penis. A ring at the base of the penis help maintain the erection. This type of device is sometimes referred to as penis pump and may be used just prior to sexual intercourse. *Hormone treatment It is rare, but some men receive hormones for their erection problem. This does depend on the cause of the problem as well as other factors. *Surgery Often, as a last resort if other treatments have failed, the most common procedure is prosthetic implants which involves the insertion of artificial rods into the penis. *Counseling

*Testosterone is a male hormone and it is the important hormone for health and well-being as well as in sexual functioning. Examples include enhanced libido, increased energy, increased production of red blood cells.

*Sustanon 250 is a trade name for an oil-based injectable blend of four esterized testosterone compounds

Follow up consultations Patient Name: Treatment number: 10 TCM Disease: Yinwei TCM Type; Decline of mingmen fire and damp heat retention underlining Kidney qi deficiency Date: 19th Nov 2008 Current conditions / Changes: Tongue; purple body with white thin watery coating, toothmark, crack in the middle Pulse; weak deep slippery He already has been treated ten times for his obesity and the infertility problem. After the first treatment he felt sleepy. His Achilles tendons pain has gone totally by the second treatment. He lost over 2kg since his first treatment. He recently exercises regularly. After the 9th treatment, he felt sever pain on his lower abdomen and he had blood in urine. The supervisor is guessing that the pain was there because of the movement of the kidney stone. He hasn’t seen a doctor for that problem yet.

Case Conclusion He is suffering from reduced testosterone, and it is causing erectile dysfunction. His weight is 80kg and it is BMI 30.9. The obesity may be the trigger for his erectile dysfunction. In TCM, the damp-heat is one of the factors of erectile dysfunction. The damp heat is usually caused by indulge of greasy food diets which damage the function of spleen and stomach causing dampness and it turns to heat. The heat travels down to penis to unable to erect. He is obesity and his body has dampness retention for many years, therefore he may have been suffering from the erectile dysfunction. He also worries about his situation and future. He feels pressure to have children, which may have damaged his mind and leading kidney deficiency. His pulse is so week and deep, also he suffers from lower back pain, hence, his condition may be more likely to be differentiated to “the declined of mingmen fire” in this present. Yinwei refers to weak erection of penis, in TCM. So far I have been treating him from both aspect [kidney deficiency and excess dampness retention]. For the damp-heat retention for the obesity, I used points like, [zhongwan, Shuidao, Tianshu, Xiawan, Dahun, Qihai, guanyuan, Neiting, Zhusanli, Hegu] to reduce the dampness. The next morning after the damp-heat treatment, he had severe spasm pain on his lower abdomen, it is the area of Dahun. The severe pain was continued whole day. His constitution is so weak, it may be caused by too much stimulation of acupuncture on his abdomen. Otherwise, the large intestine pain seems to be IBS which is the irritable bowel syndrome, and it is usually caused by stress, wrong life style and worry. My teacher has diagnosed it as Kidney stone which travelled down to his bladder, because he had a blood in his urine on that day. The stimulation of the damp-heat reduction treatment was too strong for him because he has kidney deficiency. I may need to change the choosing points. I may need to concentrate to tonify the patient first. For the chronic type diseases, I can’t see the result straight way, so I don’t know how effective these treatments are. For the acute pain on Achilles tendon worked very well. I am happy about it.

lh (luteinizing hormone; luteinising hormone)

gonadotropic hormone secreted by the pituitary gland stimulating maturation of eggs and development of the corpus luteum in females and sperm in males

Follicle-stimulating hormone (FSH) is a hormone synthesized and secreted by gonadotropes in the anterior pituitary gland. FSH regulates the development, growth, pubertal maturation, and reproductive processes of the human body. FSH and Luteinizing hormone (LH) act synergistically in reproduction