I.V.A.S. ACUPUNCTURE CASE REPORT
Francesco Longo, D.V.M., Florence.

ABSTRACT
Reining horse affected by infertility was treated with acupuncture to improve his performance at start of breeding season with good results.

HISTORY
The 13 year old quarter horse stallion was in good physical condition.
He was a champion in many reining competitions, and for this reason was assigned to reproduction.
In the past breeding season he was showing signs of reduced fertility and insufficient erection, while more mares were returning to heat.
His father and brothers were showing the same problem.
The stallion presented backache and a respiratory problem similar to exercise-induced asthma.
He had been housed alone in a stall and in small paddock; diet and nutrition were normal.
In the past, the quarter horse stallion had been treated with GnRH therapy with very little benefit.
He was also treated with homeopatic remedies, but without results.

EXAMINATION FINDINGS
Western. No abnormalities were noted on physical exam; no pain was evident on palpation, and testes were freely movable within the scrotal cavity.
Left testicle appeared thicker at epididymis level; right testicle was smaller than left.
Penis and prepuce were normal.
Palpation per rectum revealed no abnormalities of the accessory sex glands or inguinal rings; only the prostate gland was a bit hard.
Ultrasonography revealed that parenchyma of the left testicle was somewhat hyperechoic compared to right testicle.
Increased abdominal expiratory effort was evident after exercise in the paddock, along with back pain in lumbar area.
Eastern. The stallion showed normal Shen, but was apathetic and slightly depressed; eyes were normal, but complexion was dark and skin dull.
Movements were normal, but the gait was stiff.
Tongue tended to be red in color and slightly coated; pulse was thin (xi) and swift (shuo).
He presented loud breath only after exercise.
He had no particular smell.
Anamnesis revealed that the male line of his family was affected by the same problem (hereditary predisposition that involved Yuan Qi).
The palpation exam showed high sensitivity at BL 18 (Ganshu), more on the right side (sign of endogenous toxicity) and sensitivity at BL 23 (Shenshu).
During the sexual act, the stallion was extremely excited, but had difficulty achieving and maintaining erection.

DIAGNOSTICS
Breeding Soundness Examination (B.S.E.) was performed in accordance with Society of Theriogenogy guidelines (see Table 1).
The response was oligospermiae with secondary abnormalities in 50% of the sperm (kinked tails, proximal and distal cytoplasmic droplets).

WESTERN MEDICAL DIAGNOSIS
Examination findings and diagnostics suggested oligospermiae.
The palpation exam, ultrasonography and the presence of secondary abnormalities in the sperm suggested that the epididymis was affected.
The diagnosis was infertility.

EASTERN MEDICAL DIAGNOSIS
According to the 1st chapter of So Wen, the kidney supports sexual energy (sex hormones).
In the 9th chapter of So Wen, we read: "Kidney is the receptacle of creating source, is the essence of blood and of all creating matters".
The 17th chapter of So Wen says: "Lumbar area is the seat of the Kidney; if the patient is not able to move, the Kidney is losing energy".
In the 56th chapter, Qi Bo asserts: "The 57 shu points of Water are concentration points for Yin energy. The body water is borne by these points. Dyspnea appears, and Kidney and Lung are affected at the same time".
These assertions explain the involvement of the kidney and the lung, and reflect the pathological pattern in this horse: oligospermiae and respiratory difficulties.
The 37th chapter of So Wen says: "The perverse Yin invades the Liver".
This assertion explains liver involvement, which leads to high sensitivity at BL 18 (Ganshu); Kidney Yin nourishes Liver Yin (Water is mother of Wood).
Traditionally, there are six Qi Heng Zhi Fu (extraordinary Fu organs) in the body.
In the male, one of these organs is the prostate gland (corresponding to the uterus in the female), which takes the name Jing Shi, 'sperm chamber'.
This chamber stores seminal fluid and it is borne by Kidney and Ming Men ('lifegate'). It depends on two extraordinary vessels: Ren Mai (Conception Vessel - CV) and Chong Mai (Penetrating Vessel - CM).
When there are problems in erection and in sperm production (in quality and quantity), the prostate gland and stomach (assimilation and alimentary energy - Gu Qi) are always involved.
The hereditary origin of this pattern involving Yuan Qi is significant.
When there is an involvement of Anterior Heaven and Posterior Heaven, there is a problem of Yin energy.
According to Eastern examination and on the basis of classical texts, this infertility is classified as Bu Yun Yin Shen Xu (infertility by Kidney Yin deficiency).

TREATMENT
Western. GnRH therapy is indicated. Several reports based on clinical findings indicate that this therapy has beneficial effects, viz., an increase in motility, concentration and normal spermatozoa; negative effects of GnRH therapy appear to be minimal.
Therapy consists of administering GnRH every two hours, either by subcutaneus injection or by pulsatile pump.
In this case, however, GnRH therapy was not effective.
No data are available concerning homeopathic therapy, though the latter was not effective in this case.
Eastern. In human medicine, many investigations have demonstrated that acupuncture therapy improves fertility rate, in terms of the number, concentration and morphology of spermatozoa.
Bartov et al. and Sinclair have defined acupuncture as a 'valid therapeutic approach to male infertility'.
TCM devotes considerable attention to the psychic aspects of disease.

- Thus, So Wen states "In Yin deficiency disease it is necessary to nourish Water of the Kidney" , i.e., to tonify all of Yin by means of Ren Mai.
Ren Mai is the 'sea of Yin meridians', that regularizes the energy of Yin Vessel in the body, and nourishes the reproductive organs.
Ren Mai is linked to Yin Qiao Mai (Yin QM): both these vessels form the traditional couple 'Prince and Vassal'.
Yin Qiao Mai permits Yin circulation and takes the hereditary energy towards BL 1(Jingming); it supports the Gu Qi.
This information suggested needling LU 7 (Lieque) and KI 6 (Zhaohai).
Combining these two acupoints is effective in the treatment of kidney, lung, liver and heart diseases. There is a link between the Metal meridian (Shou Tai Yin) and the Water meridian (Zu Shao Yin); Metal nourishes Water, and therapeutical effects are strengthened.

- Traditional formulas mention CV 3 (Zhongji).
The name of this point refers to the Pole Star, the star involved in conception (the heavenly energy spreads between the Pole Star and GV 20 - Bai Hui - during coitus); the three Yin meridians of the foot (KI, SP, LR) meet CV at this acupoint.

- Traditional formulas also mention GV 3 (Yaoyangguan).
The name of this point refers to its function as a hinge between Yin and Yang.

- The 36th Difficulty of Nan Jing says: "The two Kidneys are not both Kidneys. The left one makes up the Kidney, while the right one makes up lifegate. The lifegate is the abode of all the spirit essence. It is the place to which the original qi is tied. In males, it stores the essence".
This information suggested treating GV 4 (Mingmen) and the surrounding lumbar area.
Cheng Fu Zheng of the Ming Dynasty, an adherent of Immortal Ge's teaching, assigned great significance to the action of moxibustion in cases of deficiency.
Accordingly, GV 4 (Mingmen) was warmed with Artemisia sinensis placed in a wooden box.

- The physiology of the prostate gland is related to Chong Mai vessel.
Chong Mai is the 'sea of Blood'', which adjusts energy and blood of twelve meridians. It influences genital functions and regulates endocrine glands.
Chong Mai is linked to Yin Wei Mai (Yin WM): both these vessels form the traditional couple 'Father and Mother'.
Yin Wei Mai distributes the Kidney Jing in the body and forms the connection between interior (Yin) and exterior (Yang).
This classical information suggested needling SP 4 (Gongsun) and PC 6 (Neiguan).
Combining these two acupoints is effective in treating the spleen, heart, liver, and stomach.
There is a link between the Fire meridian (Shou Jue Yin) and the Earth meridian (Zu Tai Yin); Fire nourishes Earth and the therapeutical effects are strengthened.

- The liver stores blood (Xue) and normalizes the function of CV, Lower Burner and genital organs.
According to tradition: Water nourishes Wood, i.e., Kidney Jing nourishes Liver Xue; but Liver Xue nourishes Marrow which produces Xue.
Xue and Jing produce each other reciprocally.
To aid liver functions and solve endogenous toxicity, LR 3 (Taichong) and LR 8 (Ququan) were needled.

- Several acupoints with global effects were also employed, viz., ST 36 (Zusanli), LI 4 (Hegu), CV 17 (Tanzhong), and BL 40 (Weizhong).
On the basis of these elements, the aim of treatment was to tonify Kidney Yin (hereditary aspect, endocrine system, prostate, epididymis) and regulate Kidney Yang (erection, ejaculation, external genitalia).

Needles Used. Acupuncture: GV 3 (Yaoyangguan), BL 18 (Ganshu), BL 47 (Hunmen): needling with Chinese sterile single-use acupuncture needles, gauge 0.30 - length 70 mm.
CV 3 (Zhongji), BL 40 (Weizhong): needling with Chinese sterile single-use acupuncture needles, gauge 0.25 - length 40 mm.
BL 1(Jingming), LU 7 (Lieque), KI 6 (Zhaohai), LR 3 (Taichong), LR 8 ( Ququan), SP 4 (Gongsun), PC 6 (Neiguan), ST 36 (Zusanli), LI 4 (Hegu), CV 17 (Tanzhong), GV 1 (Changqiang): needling with Chinese sterile single-use acupuncture needles, gauge 0.30 - length 25 mm.
Depth of stimulation: needles were inserted for their entire length in the acupoints (except BL 1 - Jingming).
All needles were stimulated until De Qi was perceived.
Hemoacupuncture: Needle gauge 0.60 - length 25 mm.
Moxibustion: Pure moxa rolls for mild moxibustion produced by China National Medicine and Health Products were used.

Acupuncture Treatment in Chronological Order.

17 January 2001

BL 1 (Jingming):

• Location: At the medial canthus of the eye, in the indention dorsal to the base of the nictating membrane.

• Function: Endocrine problem of hypothalamus, hypophysis, and pituitary glands.
• Nature of the point: Meeting point of Yin Qiao Mai, Yang Qiao Mai, GV, SI, TH, ST, BL.
• Note: Bilateral insertion; corresponds to Sui (Hexagram 17) i.e., 'Venus Point', associated with genital diseases.

LU 7 (Lieque):

• Location: Craniomedial edge of the radius, immediately proximal to the medial styloid process; 1.5 cun proximal to the transverse crease of the carpal joint; caudal to the extensor carpi radialis and cranial to the tendon of the flexor carpi radialis.
• Function: Regularizes Lung Qi, Ren Mai, tonifies Yin of the entire body, acts on penis problem.
• Nature of the point: Luo point of Lung meridian; master point for Ren Mai; master point for head and neck.
• Note: Monolateral left insertion; corresponds to Lu (Hexagram 56), which treats emotional strain and liver toxicity (Metal controls Wood).

KI 6 (Zhaohai):

• Location: Immediately distal to the medial malleolus of the tibia.
• Function: Tonifies Kidney Yin, treats prostate gland disease and regularizes external genitals.
• Nature of the point: Master point of Yin Qiao Mai; has an influnce on CV 6 (Qihai).
• Note: Monolateral right insertion; corresponds to Sun (Hexagram 57) and is involved in lumbar pathology and in diseases of genitalia.

LR 8 (Ququan):

• Location: Behind the medial condyle of the femur, in front of the tendons of the semimembranosus and semitendinosus.
• Function: Allows Liver Qi, treats testicle flogosis, removes Xue stagnations to solve impotence and external genital problems.
• Nature of the point: Water point of Liver meridian; He (sea) point of meridian; tonification point of Liver.
• Note: Monolateral left insertion; it is important to remember that from LR 8 (Ququan), the pathway of the Liver meridian surrounds and enters the genitals; corresponds to Ting (Hexagram 50), which promotes alimentary assimilation for Liver Yang functions.

GV 3 (Yaoyangguan):

• Location: Between the 4th and 5th lumbar vertebrae overlying the supraspinous ligament.
• Function: Tonifies Kidney Yang and Qi, tonifies Yuan Qi, regularizes the 'Water Way', benefits loins, treats impotence and testicle insufficiency, regularizes genital functions.
• Nature of the point: Action on thyroid gland; controls lipids and triglycerides.
• Note: Corresponds with Ts'ui (Hexagram 45), which treats illnesses arising from internal causation (imbalance of the seven emotions, sexual excess).

CV 3 (Zhongji):

• Location: 4 cun caudal to the umbelicus on the ventral midline.
• Function: Regularizes Lower Burner, treating all external genital problems; tonifies kidney, treating prostatitis, male infertility and ejaculatory problems.
• Nature of the point: Mu (alarm) point of Bladder; meeting point of LR, SP, KI with Ren Mai; gathering point of three Yin (KI, SP, LR) tendino-muscolar meridians of the hindlimb; gathering point of ST tendino-muscolar meridian.
• Note: This acupoint was treated with needling and moxibustion (a piece of moxa roll placed on the needle handle); it corresponds to Zhong Fu (Hexagram 61), which controls fertility, sexuality, head and nature (disposition).

GV 4 (Mingmen):

• Location: Between the 2nd and 3rd lumbar vertebrae, dorsal to BL 23 (Shenshu), overlying the supraspinous ligament.
• Function: Tonifies Kidney Yang and Qi, tonifies Yuan Qi, regularizes the 'Water Way', benefits loins, and treats all sexual problems, especially impotence and infertility.
• Nature of the point: According to Taoist Medicine, it nourishes the kidney and 'Cinnabar Field'.
• Note: This acupoint was warmed with moxa placed in a wooden box; it corresponds to Ts'ui (Hexagram 45), which has an influence on the spine and Kundalini coils.

Duration of therapy: 25 minutes. Needles and moxa were then removed and the following procedure was performed to support the stallion's energy:

ST 36 (Zusanli):

• Location: One finger's width from the tibial crest and head of the fibula, on the lateral side of the tibia, over the cranial tibialis muscle.
• Function: Strengthens Middle and Lower Burner, treats shortness of breath, tonifies Kidney Yang to treat impotence, combats stress by increasing Wei Qi.
• Nature of the point: Earth point of the Stomach meridians; He (sea) point of meridian; Ben (horary) point; master point for cranial abdomen and digestive system.
• Note: Bilateral insertion; corresponds to Chun (Hexagram 3), which is involved with alimentary assimilation and strengthening energy.

CV 17 (Tanzhong):

• Location: Along the ventral midline, at the level of the caudal border of the elbow.
• Function: Benefits the lung by treating dyspnea, tonifies Yuan Qi, allows the spread of Qi, treats all diseases on the ventral surface of the body, has antistress effects.
• Nature of the point: Mu (alarm) point of the Pericardium; Hui (reunion) point of respiratory energy; point 'sea of Qi'.
• Note: In many ancient texts, the Pericardium ('Master of Heart') is linked to sexuality; it corresponds to Kuan (Hexagram 20), which controls fertility, thyroid and the immune system.

Duration of this therapy: 9 minutes, after which needles were removed and stretching movements were performed.
It was suggested that the client breed the stallion 4 days after treatment and take note of the horse's behavior.

25 January 2001

The client reported that the stallion was bred to mares once a day starting 4 days after treatment, and his sexual performance was better.
The stallion showed high sensitivity on BL 18 (Ganshu) and along the column, along with a slight asthenia. The acupuncture treatment was as follows:

BL 1(Jingming):
Note: Bilateral insertion.

LU 7 (Lieque):
Note: Monolateral left insertion.

KI 6 (Zhaohai):
Note: Monolateral right insertion.

CV 3 (Zhongji):
Note: This acupoint was treated with needling and moxibustion (a piece of moxa roll placed on the needle handle).

GV 3 (Yaoyangguan):
Note: This acupoint was treated with needling and moxibustion (a piece of moxa roll placed on the needle handle).

GV 1 (Changqiang):

• Location: In a depression between the anus and ventral tail base, between the coccygeal muscle and anal sphincter.
• Function: Treats asthenia, testicle and scrotal problems, fortifies loins, has antistress effects.
• Nature of the point: Luo point of Du Mai; starting point of secondary vessel (Distinct Meridian) of Du Mai; meeting point of Ren Mai, GB, KI with Du Mai.
• Note: It corresponds to Ts'ui (Hexagram 45), with decisive action on the entire spinal column.

BL 18 (Ganshu):

• Location: 3 cun lateral to the ventral border of spinous process of the 13th thoracic vertebra, at the 13th intercostal space in the musculus iliocostalis groove.
• Function: Regularizes and tonifies Liver (Qi, Xue and Liver Yang), treats genital problems.
• Nature of the point: Shu (association) point of Liver.
• Note: Bilateral insertion; this acupoint was treated with needling and moxibustion (a piece of moxa roll placed on the needle handle); it corresponds to Sui (Hexagram 17), which helps energy flow from the spine, treats mental stagnation and sexual problems.

Duration of therapy: 25 minutes. Needles and moxa were then removed and the following procedure was performed to support the stallion's energy:

ST 36 (Zusanli):
Note: Bilateral insertion.

Duration of this therapy: 9 minutes, after which needles were removed and stretching movements were performed.
It was suggested that the client breed the stallion 4 days after treatment and take note of the horse's behavior.

1 February 2001

The client reported that the stallion was bred to mares once a day starting 4 days after treatment, and his sexual performance was better, but after coitus the horse appeared to be tired and have lumbar pain. It is important to remember that this stallion was employed as a reining horse and that this sport takes a toll on the hip and hind limbs. The horse was showing asthenia and listlessness. The acupuncture treatment was as follows:

CV 3 (Zhongji):
Note: This acupoint was treated with needling and moxibustion (a piece of moxa roll placed on the needle handle).

GV 3 (Yaoyangguan):
Note: This acupoint was treated with needling and moxibustion (a piece of moxa roll placed on the needle handle).

GV 1 (Changqiang):
Note: Needling only.

BL 40 (Weizhong):

• Location: Midpoint of the trasverse crease of the popliteal fossa, between the semitendinosus and biceps femoris muscles.
• Function: Fortifies loins, treats lumbago, helps eliminate endogenous toxins.
• Nature of the point: Earth point of Bladder meridian; He (sea) point of meridian; master point for caudal back.
• Note: Bilateral insertion. According to ancient Taoist alchemy, every subject has three treasures: vitality, energy and spirit. Vitality has its seat in the loins, so it is very important to tonify this area by means of this acupoint; it corresponds to Hsiao Ch'u (Hexagram 9), which affects the urinary tract and lumbar area, and balances the emotional life.

LR 3 (Taichong):

• Location: On the medial side of the leg, halfway down the cannon bone.
• Function: regularizes Liver (Qi, Xue, Yang and Yin), enlives Xue, regularizes Qi flow, treats lumbar ache, has intense action on testicles.
• Nature of the point: Earth point of Liver meridian; Shu (stream) point of meridian; Yuan (source) point.
• Note: Bilateral insertion; it corresponds to Shih (Hexagram 7), which works on mind, diseases caused by Kidney vacuity, venereal diseases, genital problems.

BL 18 (Ganshu):
Note: Hemoacupuncture was performed. A blood sample was taken from the jugular vein and 0.3 ml of fresh blood was immediately injected into both of these acupoints; according to tradition, the erythrocyte is the Emperor Seal - Heart - and it takes an imperial order to repair damage.

Duration of therapy: 25 minutes. Needles and moxa were then removed and the following procedure was performed to support the stallion's energy:

ST 36 (Zusanli):
Note: Bilateral insertion.

LI 4 (Hegu):

• Location: On the medial side of the leg, on the palmar border, distal to the base of metacarpeus II.
• Function: Regularizes Lung, tonifies Yang of the entire body, combats stress by increasing Wei Qi.
• Nature of the point: Yuan (source) point of Large Intestine meridian; master point for face and mouth.
• Note: Bilateral insertion; corresponds to Bi (Hexagram 22), which treats Lower Burner and lower back pain.

Duration of this therapy: 9 minutes, after which needles were removed and a transrectal massage of the prostate gland was performed.
According to a Taoist classic, the Su Nu Jing, this particular technique restores normal prostatic functions, promotes sperm production, and supports the wellbeing of the entire male body.
It was suggested that the client breed the stallion 3 days after treatment, to take note of the horse's behavior and to repeat B.S.E.

26 February 2001

The client reported that stallion attended to coitus with greater ease and without stress; the respiratory problem was reduced and B.S.E. was better (see Table 2); physical exam and ultrasonography of testes were normal; a slight sensitivity at BL 18 (Ganshu) remained. The acupuncture treatment was:

GV 3 (Yaoyangguan):
Note: This acupoint was treated with needling and moxibustion (a piece of moxa roll placed on the needle handle).

CV 3 (Zhongji):
Note: This acupoint was treated with needling and moxibustion (a piece of moxa roll placed on the needle handle).

SP 4 (Gongsun):

• Location: In a depression on the hind limb, mediodistal to the head of the medial splint bone.
• Function: Regularizes Middle and Lower Burner, enlivens Xue, treats asthenia, supports Chong Mai by regulating genital organs.
• Nature of the point: Luo point of Spleen meridian; master point for Chong Mai.
• Note: Right monolateral insertion; it is important to stabilize the energy level achieved; corresponds to Sung (Hexagram 6) for Yin/Yang disharmony, Qi/Xue disharmony and prostation.

PC 6 (Neiguan):

• Location: 2 cun above PC 7, in front of the chestnut.
• Function: Regularizes Liver Qi, tonifies Heart, benefits diaphragm, treats impotence.
• Nature of the point: Luo point of Pericardium meridian; master point for Yin Wei Mai.
• Note: Left monolateral insertion; completes the particular combination on Yin sector; performs the traditional function of Xin Bao Luo, the protective net from Heart to genitalia; corresponds to Lü (Hexagram 10), which treats cardiac activity and its emotional aspect, as well as sexual life.

BL 47 (Hunmen):

• Location: In the 15th intercostal space, lateral to BL 18 (Ganshu).
• Function: Regularizes Liver Yang and Qi, controls Hun (spiritual soul) which resides in the Liver; Hun is associated with sexual life.
• Nature of the point: Located on the external branch of the Bladder meridian.
• Note: Corresponds to Wei Chi (Hexagram 64), which treats Kidney vacuity, fatigue, Liver problems.

Duration of this therapy: 25 minutes, after which needles were removed and a transrectal massage of the prostate gland was performed.
It was suggested that the client breed the stallion 3 days after treatment, and to take note of the horse's behavior.

13 March 2001

The client reported that the stallion was bred with good results and several mares were covered with success.
The horse was more active and lively. He had no lumbar pain or sensitivity at acupoints. The last acupuncture treatment was:

ST 36 (Zusanli):
Note: Bilateral insertion.

LI 4 (Hegu):
Note: Bilateral insertion.

CV 3 (Zhongji):
Note: This acupoint was treated with needling and moxibustion (a piece of moxa roll placed on the needle handle).

GV 3 (Yaoyangguan):
Note: This acupoint was treated with needling and moxibustion (a piece of moxa roll placed on the needle handle).

Duration of this therapy: 25 minutes; after which needles were removed and a transrectal massage of the prostate gland was performed.

DISCUSSION

Acupuncture is very effective in treating this kind of pathology, in which there are many physical (endocrine system, genitalia, endogenous toxicity) and psychic (the horse was no longer used in competition, and his life was too monotonous) problems based on hereditary predisposition.
As in human medicine, the study of ancient texts is very important in understanding diseases and their treatments by means of carefully selected acupoints.

ADDENDUM

Table 1

Table 2