Written by a Medical Acupuncture for Veterinarians course graduate. Signed release obtained from client/author. A2017037
Abstract: A 16 year old multiparous Paint broodmare was evaluated for reproductive failure. The mare had been bred three previous cycles in the spring of 2017, without a resulting conceptus. All three previous cycles the mare had significant delay in uterine clearance and fluid pooling post breeding. She was previously managed with aggressive uterine lavages, ecbolics, and exercise. Despite aggressive medical management she had failed to clear the fluid by day 4 post ovulation and did not conceive. A fourth cycle was attempted with pre and post breeding acupuncture in combination with uterine lavage, ecbolics, and exercise as used in the three previous cycles. Fluid clearance was achieved by day 4 and a resulting conceptus was noted at a 15 and 30 day check.
History and Presentation: In March of 2017, a 16 year old Paint multiparous broodmare presented for breeding via artificial insemination. The mare had previously had 4 foals, but had not been bred for many years and last foaling date was unknown. The mare was managed for three cycles from March-May with aggressive advanced reproductive techniques. She continued to demonstrate evidence of delayed uterine clearance and fluid pooling, and did not conceive.
Physical Examination and Clinical Assessments: On physical exam the mare had a good body condition score of 5 and a normal physical exam. Myofascial palpation revealed sensitivity over the brachiocephalicus and sternocephalicus muscles as well as the caudal thoracic and lumbar regions of the back. It was previously unknown but confirmed at this time with the owner that the mare had an old front end lameness. There was no evidence of metabolic disorders or any other illness that may predispose her to being unable to conceive or carry a foal. An endogenous ACTH test was performed to look at pituitary function and was within normal limits. Uterine culture was negative and uterine cytology was within normal limits. Transrectal ultrasound of ovaries and uterus were within normal limits. Post mating endometritis with fluid retention and delayed uterine clearance due to decreased uterine contractility remained her primary issue.
Medical Decision Making: Due to continued fluid pooling and delayed uterine clearance, aggressive post breeding medical management was necessary. However, all common known medical treatments for post mating endometritis, delayed uterine clearance, and fluid pooling were already attempted. There was limited further western medical options. Acupuncture was initiated to treat both the pain in the front end based on the myofascial exam as well as the stimulating the pudendal, femoral, sciatic, and local spinal nerves to influence uterine contractility.
Differential Diagnoses: Uterine atony with delayed uterine clearance was the top differential and primary concern. A second differential was a poor quality uterus which a uterine biopsy could help determine. Front end lameness was also a factor and likely causing pain which could influence conception rate as well.
Definitive (or Putative) Diagnosis (or Diagnoses): Post mating endometritis with delayed uterine clearance and fluid pooling due to uterine atony.
Acupuncture Treatments: Acupuncture treatments were started approximately 48 hours prior to breeding. She was treated once daily for 2 days prior to breeding and then treated 4 hours post
breeding, and once daily for 3 days following breeding. Myofascial palpation was performed prior to each session and treatment was slightly modified at each time based on the findings of the exam. A combination of BL 10, LI 16, LI 17, ST 10, and GB 21 were used to address the forelimb lameness and sensitivity based on the myofascial exam. The pudendal nerve along with local spinal nerves as well as the sciatic and femoral nerves were stimulated for uterine clearance by using BL 26, 27, 28, 29, 30, 54, Bai Hui, GB29,30 at each acupuncture session. KI 3 would also be a good point to use that stimulates the tibial nerve as a reproductive point, but was not used on this mare. Dry needling was used in this case, but electroacupuncture would be a good addition to treatment as well as laser over the lower thoracic and lumbar regions.
Outcomes, Discussions, and References: Uterine clearance was visibly noted within 5 minutes of placing the needles. The needles were stimulated and left in place for about 20 minutes per session. Uterine lavages and ecbolics were used simultaneously. Transrectal ultrasound showed trace fluid present for 2 days post ovulation, but on day 3 no fluid was noted. One last acupuncture treatment was performed on day 3. On day 15 post ovulation an embryo was noted and re-checked at day 30 with positive heart beat. A 2006 article from Michelle LeBlanc discussed clinical cases of equine reproduction and infertility. It mentions the use of acupuncture in the older mare in combination with ecbolics and uterine lavage to increase uterine clearance and pregnancy rates as un unpublished observation. Multiple human studies have looked at acupuncture while pregnant and/or possibly increasing contractions during labor. Studies have assumed increase blood flow to the uterus leads to increased uterine contractions. Although it can be difficult to correlate the increased pregnancy rate with acupuncture alone due to variation in each breeding cycle, most studies have shown a correlation to increased pregnancy rates with acupuncture especially in the older mare. https://aaep.org/sites/default/files/issues/proceedings-06proceedings-z9100106000585.PDF http://aim.bmj.com/content/acupmed/early/2010/10/18/aim.2009.002022.full.pdf http://aim.bmj.com/content/acupmed/33/5/413.full.pdf