ArticlePDF Available

Reduction of blood flow impedance in the uterine arteries of infertile women with electro-acupuncture



In order to assess whether electro-acupuncture (EA) can reduce a high uterine artery blood flow impedance, 10 infertile but otherwise healthy women with a pulsatility index (PI) ≥3.0 in the uterine arteries were treated with EA in a prospective, non-randomized study. Before inclusion in the study and throughout the entire study period, the women were down-regulated with a gonadotrophin-releasing hormone analogue (GnRHa) in order to exclude any fluctuating endogenous hormone effects on the PL The baseline PI was measured when the serum oestradiol was ≤0.1 nmol/1, and thereafter the women were given EA eight times, twice a week for 4 weeks. The PI was measured again closely after the eighth EA treatment, and once more 10–14 days after the EA period. Skin temperature on the forehead (STFH) and in the lumbosacral area (STLS) was measured during the first, fifth and eighth EA treatments. Compared to the mean baseline PI, the mean PI was significantly reduced both shortly after the eighth EA treatment (P < 0.0001) and 10–14 days after the EA period (P < 0.0001). STFH increased significantly during the EA treatments. It is suggested that both of these effects are due to a central inhibition of the sympathetic activity.
Human Reproduction vol.11 no.6 pp.1314-1317, 1996
Reduction of blood flow impedance in the uterine
arteries of infertile women with electro-acupuncture
Elisabet Stener-Victorin
, Urban Waldenstrdm
Sven A.Andersson
and Matts Wikland
'Department of Obstetrics and Gynaecology,
Fertility Centre
Scandinavia, Department of Obstetrics and Gynaecology and
Department of Physiology, University of Gothenburg,
S-413 45 Gothenburg, Sweden
^o whom correspondence should be addressed at: Department of
Obstetrics and Gynecology, KvinnokJiniken, Sahlgrenska sjukhuset,
S-413 45 Gothenburg, Sweden
In order to assess whether electro-acupuncture (EA) can
reduce a high uterine artery blood flow impedance, 10
infertile but otherwise healthy women with a pulsatility
index (PI) 5*3.0 in the uterine arteries were treated with EA
in a prospective, non-randomized study. Before inclusion in
the study and throughout the entire study period, the
women were down-regulated with a gonadotrophin-releas-
ing hormone analogue (GnRHa) in order to exclude any
fluctuating endogenous hormone effects on the PL The
baseline PI was measured when the serum oestradiol was
=s0.1 nmol/1, and thereafter the women were given EA
eight times, twice a week for 4 weeks. The PI was measured
again closely after the eighth EA treatment, and once more
10-14 days after the EA period. Skin temperature on the
forehead (STFH) and in the lumbosacral area (STLS) was
measured during the first, fifth and eighth EA treatments.
Compared to the mean baseline PI, the mean PI was
significantly reduced both shortly after the eighth EA
treatment (P < 0.0001) and 10-14 days after the EA period
(P < 0.0001). STFH increased significantly during the EA
treatments. It is suggested that both of these effects are
due to a central inhibition of the sympathetic activity.
Key words: electro-acupuncture/pulsatility index (PI)/trans-
vaginal colour Doppler curve/uterine artery blood flow
merits done on the day of oocyte retrieval compared with PI
measurements on the day of embryo transfer. This would allow
prediction of non-receptive endometria earlier in the cycle.
Previous studies on rats have shown a decreased blood
pressure after electro-acupuncture (EA) with low frequency
(2 Hz) stimulation of muscle afferents (A-8 fibres). The
decreased blood pressure was related to reduced sympathetic
activity (Yao etal, 1982; Hoffman and Thor6n, 1986; Hoffman
et al, 1987, 1990a,b), and was paralleled by an increase in
the P-endorphin concentration in the cerebrospinal fluid (CSF),
suggesting a causal relationship to central sympathetic inhibi-
tion (Cao et al, 1983; Moriyama 1987; Reid and Rubin,
The cardiovascular effects of acupuncture treatment are
probably mediated by central opioid activity via the [J-endor-
phin system from the hypothalamus.
The aim of this study was to evaluate whether EA can
reduce a high impedance in the uterine arteries. There are
several conceivable mechanisms which may give this effect
In addition to central sympathetic inhibition via the endor-
phin system, vasodilatation may be caused by stimulation of
sensory nerve fibres which inhibit die sympathetic outflow at
the spinal level, or by antidromic nerve impulses which release
substance-P and calcitonin gene-related peptide from peripheral
nerve terminals (Jansen et al, 1989; Andersson, 1993;
Andersson and Lundeberg, 1995).
It has been assumed that various disorders in the autonomic
nervous system, such as hormonal disturbances, may be
normalized during auricular acupuncture (Gerhard and
Postneck, 1992). It has also been suggested that the concentra-
tions of central opioids may regulate the function of the
'hypodialamic^jituitary-ovarian axis via the central sym-
pathetic system, and that a hyperactive sympathetic system in
anovulatory patients could be normalized by EA (Chen and
Yin, 1991).
Successful in-vitro fertilization (IVF) and embryo transfer
demand optimal endometrial receptivity at the time of implanta-
tion. Blood flow impedance in die uterine arteries, measured
as die pulsatility index (PI) using transvaginal ultrasonography
with pulsed Doppler curves, has been considered valuable in
assessing endometrial receptivity (Goswamy and Steptoe,
Sterzik et al, 1989; Steer et al, 1992, 1995a,b; Coulam
et al, 1995; Tekay et al, 1995). Steer et al. (1992) found that
a PI
at the time of embryo transfer could predict 35%
of the failures to become pregnant Coulam et al. (1995) did
not observe any significant differences between PI measure-
Materials and methods
Subjects, design and PI measurements
Tlie study was approved by the ethics committee of the University
of Gothenburg and was conducted at the Fertility Centre Scandinavia,
Gothenburg, Sweden, a tertiary private IVF unit All women attending
the clinic for information about the IVF/embryo transfer procedure
had the PI of their uterine arteries measured by transvaginal ultrasono-
graphy and pulsed Doppler curves (Aloka SSD 680. Berner Medecin-
teknik, Stockholm, Sweden). The PI value for each artery was
calculated electronically from a smooth curve fitted to the average
waveform over three cardiac cycles, according to the formula: PI =
(A - B)/mean, where A is the peak systolic Doppler shift, B is the
end diastolic shift frequency and mean is the mean maximum Doppler
© European Society for Human Reproduction and Embryology
by guest on July 13, 2011humrep.oxfordjournals.orgDownloaded from
Uterine artery Mood flow and electro-acupuncture
shifted frequency over the cardiac cycle. A reduction in the value of
PI is thought to indicate a reduction in impedance distal to the point
of sampling (Steer et al., 1990).
In the routine preparation for their IVF/embryo transfer treatment,
all women were down-regulated with a gonadotrophin-rcleasing
hormone analogue (GnRHa) (Suprecur Hoechst, Germany). When
their oestradiol concentration in serum was <0.1
the women
were considered down-regulated and the PI of their uterine arteries
was again measured in those women showing a mean PI &3.0 before
down-regulation. The measurements were done by two of the authors
(M.W. and U.W.) between 08.30 h and 14.30 h. These hours were
chosen for practical reasons, and also to reduce the risk that the PI
measurements would be affected by the circadian rhythm in blood
flow, recently reported by Zaidi et aL (1995). Three measurements
were made on the right and three on the left uterine artery of each
patient Before the study was conducted, the observers were well
trained in PI measurements with the equipment used. Steer et al
(1995) has shown that in trained hands, the inter-, and intra-observer
variations in vaginal colour Doppler ultrasound are sufficiently small
to provide a basis for clinically reliable work.
PI measurements were done on all women attending the unit for
an IVF/embryo transfer treatment between November 1992 and
February 1993. Of these, all infertile but otherwise healthy women,
with a mean PI &3.0 in the uterine arteries both before and after
down-regulation, were invited to be included in the study.
In all, 10 women accepted after informed consent and they had a
mean age of 32.3 years (range 25-40 years). The infertility diagnoses
were unexplained infertility (n = 6), tubal factor (n = 3) and
polycystic ovarian syndrome (n = 1).
From their inclusion and onwards, the women were kept on
the GnRHa and were given no other pharmacological treatment
Consequently, their gonadotrophins and ovarian steroids were kept at
a constantly low concentration, both at their inclusion in the study
and throughout the whole study period. Thus, PI changes due to
hormonal fluctuations were avoided.
EA was then given eight times, twice a week for 4 weeks. The
mean PI of the uterine arteries was measured (mean of three PI on
each side) directly after the eighth EA treatment and again 10-14
days after the EA period.
Of the 10 women included, two were later excluded. One of them,
with tubal factor infertility, was excluded because she started taking
medications for her migraine, which could have affected her PI. The
other excluded woman, with unexplained infertility, stopped her
GnRHa treatment because she preferred IVF/embryo transfer in a
natural cycle.
Acupuncture treatment
The sympathetic outflow may be inhibited at the segmental level and,
for this reason, acupuncture points were selected in somatic segments
according to the innervation of the uterus (Thl2-L2, S2-S3) (Bon-
ica, 1990).
The needles were inserted i.m. to a depth of 10-20 mm. The aim
of the stimulation was to activate group III muscle-nerve afferents.
The needles were twirled to evoke 'needle sensation', often described
as tension, numbness, tingling and soreness, sometimes radiating
from the point of insertion. The needles were then attached to an
electrical stimulator (WQ-6F: Wilkris & Co. AB, Stockholm, Sweden)
for 30 min. The location of the needles was the same in all women
(Table I).
Four needles were located bilaterally at the thoracolumbar and
lumbosacral levels of the erector spinae, and were stimulated with
high frequency (100 Hz) pulses of 03 ms duration. The intensity
was low, giving non-painful paraesthesia.
Mean PI
3.4 -r
first EA
10-14 days
after EA
Figure 1. The mean pulsatility index (PI) (n = 8) for all women
before the first electro-acupuncture (EA) treatment, immediately
after the eighth EA treatment and 10-14 days after the EA period.
***= significant changes (P < 0.0001) compared to the mean PI
before the first EA treatment
Table I.
Acupuncture points, their anatomical position and their innervation
Segmental innervation
(afferent muscle)
2, 3
5, SI, 2,3
5, S2, 3
Muscle localization
Erector spinae thoracolumbale
Erector spinae lumbosacrale
Tibialis posterior at the medial
Gastrocnemius and m. soleus at
the dorsal side
'All were placed bilaterally.
BL = bladder channel.
SP = spleen channel.
Four needles were located bilaterally in the calf muscles, and were
stimulated with low frequency (2 Hz) pulses of 0.5 ms duration. The
intensity was sufficient to cause local muscle contractions.
Skin temperature
The skin temperature was measured with a digital infrared thermo-
meter (Microscanner D-series: Exergen, Watertown, MA, USA)
between the applied acupuncture needles in the lumbosacral region
(25 mm from each needle), skin temperature lumbosacral (STLS), and
on the forehead, skin temperature forehead (STFH). The measurements
were made during the first, fifth and eighth EA treatments. The first
measurements were made after 10 min rest, and just before the EA,
these being considered as 'baseline'. Thereafter, further measurements
of STLS and STFH were done every seventh minute during the EA
and immediately after the EA. The room temperature was constant
during the three EA treatments.
Analysis of variance (ANOVA; Newman-Keul's range test) was used
to analyse the data.
Blood flow impedance
Compared to the mean baseline PI, the mean PI was signific-
antly reduced both soon after the eighth EA treatment
(P < 0.0001) and 10-14 days after the EA period (P <
0.0001) (Figure 1), at which time six women had a mean PI
<2.6 (Table II and Figure 2).
The right and left uterine arteries responded similarly to
by guest on July 13, 2011humrep.oxfordjournals.orgDownloaded from
ILStener-Vlctorin et al
1 patients
Before down-
first EA
eight EA
B 10-14 days
after EA
Figure 2. The individual mean pulsatility index (PI) before down-regulation, before the first electro-acupuncture (EA) treatment,
immediately after the eighth EA treatment and 10-14 days after the EA period.
Table H. The individual mean pulsatility index
EA treatment, 10-14 days after the EA period.
PI value
Before down-regulation
Before EA
After eight EA
10-14 days after eight EA
before down-regulation,
average mean values
Individual patients
before the first
electro-acupuncture (EA)
after the eighth
Mean value
14 21 30
EA (mln)
Figure 3. Pooled mean values (n = 8) of skin temperature on
forehead (STFH) and skin temperature in the lumbosacral area
(STLS) during the first, fifth and eighth electro-acupuncture (EA)
treatments. *= significant changes (P = 0.02) after 21 min and
**= significant changes (P = 0.002) immediately after EA
compared to the time just before needles were inserted.
0 = 'baseline'.
EA. The difference in mean PI between the two arteries was
=£0.3 (not significant), both before down-regulation, during
down-regulation and throughout the whole study period. There
was no significant difference in the mean PI for patients with
different causes of infertility.
Skin temperature
The pooled results from all skin temperature measurements
are presented in Figure 3. Compared with the starting point,
mean STFH increased significantly after 21 min of EA (P =
0.02), and directly after the EA treatments (P = 0.002). STLS
did not change significantly.
It has been shown in previous studies that a high PI in the
uterine arteries is associated with a decreased pregnancy rate
following rVF-embryo transfer (Goswamy et al., 1988; Sterzik
et al, 1989; Steer et al, 1992, 1995a,b; Coulam et al., 1995).
The results reported by Tekay et al. (1995) support the
hypothesis postulated by Steer et al. (1992) that uterine
receptivity is improved when the PI value is between 2.0 and
2.99 on the day of embryo transfer. When a high PI is found
before embryo transfer in a stimulated cycle, treatment options
are few. Goswamy et
(1988) successfully tried pre-treatment
with exogenous oestrogens in the next cycle, but their results
have not been verified by others. It has been proposed that the
embryos should be frozen, thawed and transferred in an
unstimulated cycle (Goswamy et al., 1988; Steer et al, 1992,
but there is little support for the hypothesis that the PI
would be lower under these conditions.
In experiments on spontaneously hypertensive rats, EA at
low frequency (2-3 Hz) induced a long-lasting, significant fall
in blood pressure which was associated with decreased activity
in sympathetic fibres (Yao et ah, 1982; Hoffman and Thore'n,
Hoffman et al, 1987, 1990a,b). A decrease in sym-
pathetic activity appears to be generalized. In microneuro-
graphic studies on humans, EA in the upper limbs resulted in
an initial increase and then a decrease in the activity of
sympathetic efferents in the
nerve, with a parallel increase
in the temperature of the skin (Moriyama, 1987). Kaada (1982)
reported that transcutaneous stimulation of acupuncture points
in the hand increased the skin temperature, giving pain relief
in limbs suffering from Reynaud's phenomenon. Kaada (1982)
also found that electrical stimulation of acupuncture hand
by guest on July 13, 2011humrep.oxfordjournals.orgDownloaded from
Uterine artery blood flow and electro-acupuncture
points in patients with ischaemic conditions of the lower limbs,
increased the skin temperature in the lower limbs and possibly
enhanced the healing of long-standing ulcers. It has been noted
in both animals and humans that EA has greater effects on
pathological conditions, e.g. hypertension or hypotension,
whereas normal blood pressure is only slightly changed (Yao
et al, 1982; Hoffman and Thor6n, 1986; Hoffman et al., 1987,
The mechanisms of sympathetic inhibition following EA
are poorly understood. Based on animal experiments, Hoffmann
and Thoren (1986) and Hoffman et al. (1987, 1990a,b) sug-
gested that electrical stimulation of muscle afferents innervating
ergoreceptors increases the concentration of pVendorphin in
the CSF. They found support for the hypothesis that the
hypothalamic P-endorphinergic system has inhibitory effects
on the vasomotor centre, and thereby a central inhibition of
sympathetic activity. It has been suggested that this central
mechanism, involving hypothalamic and brain stem systems,
is important in changing the descending control of many
different organ systems, including the vasomotor system
(Andersson, 1993; Andersson and Lundeberg, 1995).
In this study, the PI of the uterine arteries was significantly
decreased soon after the eighth EA treatment and remained
significantly decreased 10-14 days after the EA period. These
findings suggest that a series of EA treatments increases the
uterine artery blood flow. Another effect observed in this study
was the significantly increased STFH during the EA treatments.
The most likely cause of these effects is a decreased tonic
activity in the sympathetic vasoconstrictor fibres to the uterus
and an involvement of the central mechanisms with general
inhibition of the sympathetic outflow, in accordance with
previously observed EA effects (Kaada, 1982; Yao et al, 1982;
Cao et al, 1983; Hoffman and Thoren, 1986; Hoffman et al,
1990a,b; Moriyama, 1987; Reid and Rubin, 1987; Jansen
et al, 1989).
In conclusion, the present study showed a decrease of the
PI in the uterine arteries following EA treatment. Randomized
studies on a greater number of patients are needed to verify
these results and to exclude non-specific effects.
Andersson, S.A. (1993) The functional background in acupuncture effects.
J. Rehab. Med Suppl., 29, 31-60.
Andersson, S.A. and Lundeberg, T. (1995) Acupuncture - from empiricism
to science: functional background to acupuncture effects in pain and disease.
Med Hypoth., 45,
Bonica, J. (1990) The Management of Pain, vol. I, 2nd edn, revised. Lea &
Febiger, Philadelphia, London, 156 pp.
X.D., Xu, S.F. and Lu, W.X. (1983) Inhibition of sympathetic nervous
system by acupuncture. Acupuncture Electro-Ther. Res. Int. J., 8, 25-35.
Chen, B.Y. and Jin,
(1991) Relationship between blood radioimmunoreactive
beta-endorphin and hand skin temperature during the electro-acupuncture
induction of ovulation. Acupuncture Electro-Ther. Res. Int. J., 16, 1-5.
Coulam, C.B., Stem, JJ., Soenksen, D.M., Britten, S. and Bustillo, M. (1995)
Comparison of pulsatility indices on the day of oocyte retrieval and embryo
transfer. Hum.
10, 82-84.
Goswamy, R.K. and Steptoe, P.C. (1988) Doppler ultrasound studies of the
uterine artery in spontaneous ovarian cycles. Hum.
3, 721-726.
Goswamy, R.K., Williams, G. and Steptoe, P.C. (1988) Decreased uterine
perfusion - cause of infertility. Hum.
3, 955-959.
Gerhard, I. and Postneck, F. (1992) Auricular acupuncture in the treatment of
female infertility. GynecoL Endocrinol., 6,
Hoffmann, P. and Thoren, P. (1986) Long-lasting cardiovascular depression
induced by acupuncture-like stimulation of the sciatic nerve in
unanaesthetized rats. Effects of arousal and type of hypertension. Ada
127, 119-112.
Hoffman, P., Friberg, P., Ely, D. and Thorfn, P. (1987) Effect of spontaneous
running on blood pressure, heart rate and cardiac dimension in developing
and established spontaneous hypertension in rats. Ada Physiol
Hoffman, P., Skarphedinsson, J.O., Delle, M. and Thortn, P. (1990a) Electrical
stimulation of the gastrocnemius muscle in spontaneously hypertensive rat
increases the pain threshold: role of different serotonergic receptors. Ada
Hoffman, P., Terenius, L. and Thor6n, P. (1990b) Cerebrospinal fluid
immunoreactive beta-endorphin concentration is increased by long-lasting
voluntary exercise in the spontaneously hypertensive rat. ReguL Pept., 28,
Jansen, G., Lundeberg, T., Kjartansson, J. and Samuelsson, U.E. (1989)
Acupuncture and sensory neuropeptides increase cutaneous blood flow in
NeuroscL Lett., 97, 305-309.
Kaada, B. (1982) Vasodilatation induced by transcutaneous nerve stimulation
in peripheral ischemia (Raynaud's phenomenon and diabetic
polyneuropathy). Eur. Heart J., 3, 303—314.
Moriyama, T. (1987) Microneurographic analysis of the effects of acupuncture
stimulation on sympathetic muscle nerve activity in humans: excitation
followed by inhibition. Nippon Seirigahi Zasshi., 49,
Reid, J.L. and Rubin, P.C. (1987) Peptides and central neural regulation of
circulation. Physiol. Rev., 67, 725-749.
Steer, C.V., Campbell, S., Pampiglione, J.S. et al. (1990) Transvaginal colour
flow imaging of uterine arteries during the ovarian and menstrual cycles.
Steer, C.V., Campbell, S., Tan, S.L. et al. (1992) The use of transvaginal
colour flow imaging after in vitro fertilization to identify optimum uterine
conditions before embryo transfer. FeniL Steril., 57, 372-376.
Steer, C.V., Tan, S.L., Mason, BA. and Campbell, S. (1994) Midluteal-phase
vaginal color Doppler assessment of uterine artery impedance in a subfertile
population. FertiL Steril., 61, 53-58.
Steer, C.V., Williams, J., Zaidi, J, Campbell, S. and Tan, S.L. (1995a) Intra-
observer, interobserver, interultrasound transducer and intercycle variation
in colour Doppler assessment of uterine artery impedance. Hum.
Steer, C.V., Tan, S.L., Mason, BA. and Campbell, S. (1995b) Vaginal
color Doppler assessment of uterine artery impedance correlates with
immunohistochemical markers of endometrial receptivity required for the
implantation of an embryo. FertiL Steril., 61, 101-108.
Sterzik, K-, HUtter, W., Grab, D. el al (1989) Doppler sonographic findings
and their correlation with implantation in an in vitro fertilization program.
Fertil. SteriL, 52, 825-828.
Tekay, A., Martikainen, H. and Jouppila, P. (1995) Blood flow changes in
uterine and ovarian vasculature, and predictive value of transvaginal pulsed
colour Doppler ultrasonography in an in-vitro fertilization programme.
10, 688-693.
T., Andersson, S. and Thoren, P. (1982) Long-lasting cardiovascular
depressor response following sciatic stimulation in SHR. Evidence for the
involvement of central endorphin and serotonin systems. Brain Res., 244,
Zaidi, J., Jurkovic, D., Campbell, S. et al (1995) Description of circadian
rhythm in artery blood flow during the peri-ovulatory period. Hum.
Received on June 27, 1995; accepted on March 20, 1996
by guest on July 13, 2011humrep.oxfordjournals.orgDownloaded from
... These then increase pulsatile release of gonadotropin releasing hormone (GnRH), which increases pituitary secretion of gonadotropin and thereby steroid release [10][11][12]. In addition, acupuncture may downregulate sympathetic tone, allowing for increased blood flow to the uterus and ovaries [13]. These conditions may increase endometrial growth and thickness, creating a more hospitable environment for implantation. ...
... Submit Article fertility [10][11][12][13]. Acupuncture has additionally been hypothesized to decrease sympathetic activity [13]. ...
... Submit Article fertility [10][11][12][13]. Acupuncture has additionally been hypothesized to decrease sympathetic activity [13]. This may impact uterine blood flow and therefore endometrial growth and thickness. ...
... Firstly, for the stimulation of ovary induction, electro-acupuncture can alter several different neuroendocrinological factors, such as β-endorphin, which can mediate the hypothalamus-pituitarygonadal (HPG) and-adrenal axes (HPA) and regulate the menstrual cycle, ovulation, and fertility (7). Secondly, electroacupuncture can circulate the blood flow of the uterus, reduce the resistance of uterine arteries (8), and increase ovarian blood flow through the ovarian sympathetic nerves (9). Thirdly, acupuncture may have the efficacy of meditating the immune response for the achievement and maintenance of a successful pregnancy (10). ...
Full-text available
Background Progress has been achieved by using acupuncture widely for poor endometrial receptivity (PER). However, different acupuncture dosages may lead to controversy over efficacy. Objective To evaluate the evidence-based conclusions of dose-related acupuncture on infertile women with PER. Method References were retrieved from nine databases from inception to 26 February 2022. This meta-analysis included randomized controlled trials (RCTs) that investigated the dose-related efficacy of acupuncture for PER with outcomes of endometrium receptivity (ER) parameters by transvaginal sonography (TVS) and the subsequent pregnancy outcomes in three acupuncture-dose groups: the high-dosage group (three menstrual cycles), the moderate-dosage group (one menstrual cycle), and the low-dosage group (two or four days). Since there remained sufficient heterogeneity among the three subsets, we prespecified seven subgroup variables (four clinical and three methodological) to investigate the heterogeneities. Results A total of 14 RCTs (1,564 women) of moderate or low overall quality were included. The results were different when the dosage of acupuncture was restricted. For the moderate or high-dosage group, CPR and part of ER parameters were improved in the acupuncture group (i.e., CPR: OR = 2.00, 95% CI [1.24, 3.22], p = 0.004, I ² = 0% in one menstrual cycle; OR = 2.49, 95%CI [1.67, 3.72], p < 0.05, I ² = 0% in three menstrual cycles). However, for the low-dosage group, no statistical difference was observed in CPR (OR = 0.07, 95% CI [−0.10, 0.23], p = 0.44, I ² = 82%) and a part of the ER parameters. In subgroup analysis, four subgroup variables (the routine treatment, risk of performance bias, duration of acupuncture treatment, and the age of participants) could explain some of the heterogeneities across all trials. Conclusion The finding indicated that the trend of relatively more acupuncture dosage showed better effects for poor endometrial receptivity among PER women. It remains a potential heterogeneity in our studies. Further high-quality trials with a homogeneity trial design need to be conducted.
... Acupuncture has been proven to encourage the circulation of blood in the pelvic cavity and improve ovarian function [5]. Some studies have recommended that acupuncture can be beneficial in promoting follicle production [6], enhancing uterine blood flow, [7,8] improving uterine lining thickness9,, 10 and increasing endometrial receptivity during the implantation period [11,12] Acupuncture has also been counselled as a valuable alternative therapy for female infertility due to hormone disorders [13]. Acupuncture helps the woman's natural hormone cycle by influencing the hypothalamic pituitary gonadal axis (HPG axi--ovarian hormone feedback loops). ...
... With its central sympathoinhibitory effect, acupuncture may contribute to reducing uterine artery impedance and increasing blood flow to the uterus. In fact, Victorin et al. demonstrated that when they performed acupuncture on 10 infertile women who were downregulated by a gonadotropin-releasing hormone analog to avoid the effect of endogenous hormones on uterine artery blood flow 22 . ...
Background: Primary ovarian insufficiency (POI) is a common cause of infertility and usually defined by the triad of amenorrhea, estrogen deficiency, and elevated luteinizing hormone (LH) and follicle-stimulating hormone (FSH) levels in women < 40 years of age. The aim of the present study was to investigate the relationship between uterine and ovarian blood flow with acupuncture and fertility ratio in patients of the Firoozgar Hospital Infertility Clinic. Methods: Twenty-nine patients with POI were included in this clinical trial. FSH, LH, estradiol (E2), and anti-Müllerian hormone (AMH) levels were measured. Patients with Turner syndrome were identified and excluded from the study. Selected patients were evaluated using transvaginal color Doppler sonography used to measure ovarian volume, endometrial thickness, flow rates, and uterine and ovarian artery indexes. Patients were treated with acupuncture twice a week for 5 weeks. After the end of treatment, hormonal assays and an ultrasound examination were repeated to check the changes. Results: Indexes of the uterine arteries (Resistance Index, Pulsatility Index) before versus after the intervention were significantly different (P < 0.00) and uterine vascularity increased after treatment in 22 patients (75.8%). LH and FSH hormone levels were significantly decreased after the intervention (P < 0.00), while AMH and E2 levels were significantly increased after treatment (P < 0.00). The post-intervention right ovarian reserve was significantly increased (P = 0.02), whereas there was no significant difference in left ovarian reserve before vs. after treatment (P = 0.39). Spontaneous menstruation was detected after acupuncture in 16 patients. Conclusions: Our study demonstrated changes in vascularity, hormone levels, menopausal symptoms, and menstrual induction in patients after acupuncture intervention. Keywords: POI, acupuncture, arterial indexes.
... Acupuncture could increase the ovarian blood flow through the inhibition of ovarian sympathetic nerve activity [47,48]. A previous study reported that eight sessions of electroacupuncture treatment over a period of 4 weeks alleviated the high uterine artery blood flow impedance of women with infertility [49]. In contrast, enhancement of ovarian vascularization with aspirin could improve ovarian responsiveness and pregnancy rates in patients undergoing IVF treatment [50], while L-arginine supplementation increases the vascularization of ovarian follicles, thus becoming more permeable to plasma proteins and stimulating circulation of FSH and the growth hormone in ovarian follicles [51]. ...
Full-text available
Acupuncture is believed to improve ovarian reserve and reproductive outcomes in women undergoing in vitro fertilization (IVF). This study was conducted to evaluate the effect of network-optimized acupuncture followed by IVF on the oocyte yield in women showing a poor ovarian response. This study was an exploratory randomized controlled trial conducted from June 2017 to January 2020 at the Pusan National University Hospital. Women diagnosed with poor ovarian response were enrolled and randomly divided into two groups: IVF alone and Ac + IVF groups (16 acupuncture sessions before IVF treatment). Eight acupoints with high degree centrality and betweenness centrality were selected using network analysis. Among the participants, compared with the IVF treatment alone, the acupuncture + IVF treatment significantly increased the number of retrieved mature oocytes in women aged more than 37 years and in those undergoing more than one controlled ovarian hyperstimulation cycle. The negative correlation between the number of retrieved mature oocytes and consecutive controlled ovarian hyperstimulation cycles was not observed in the Ac + IVF group irrespective of the maternal age. These findings suggest that physicians can consider acupuncture for the treatment of women with poor ovarian response and aged > 37 years or undergoing multiple IVF cycles.
... Steer et al. found that when the uterine artery pulsatility index >3.0, the pregnancy rate would be decreased [68]. Meanwhile, Stener-Victorin et al. confirmed that the uterine artery pulsatility index decreased after a series of acupuncture treatments [69]. e results of Ho et al. also confirmed that the pulsatility index of the uterine artery in the acupuncture group was significantly reduced [70]. ...
Full-text available
Female infertility is a state of fertility disorder caused by multiple reasons. The incidence of infertility for females has significantly increased due to various factors such as social pressure, late marriage, and late childbirth, and its harm includes heavy economic burden, psychological shadow, and even marriage failure. Conventional solutions, such as hormone therapy, in vitro fertilization (IVF), and embryo transfer, have the limitations of unsatisfied obstetric outcomes and serious adverse events. Currently, complementary and alternative medicine (CAM), as a new treatment for infertility, is gradually challenging the dominant position of traditional therapies in the treatment of infertility. CAM claims that it can adjust and harmonize the state of the female body from a holistic approach to achieve a better therapeutic effect and has been increasingly used by infertile women. Meanwhile, some controversial issues also appeared; that is, some randomized controlled trials (RCTs) confirmed that CAM had no obvious effect on infertility, and the mechanism of its effect could not reach a consensus. To clarify CAM effectiveness, safety, and mechanism, this paper systematically reviewed the literature about its treatment of female infertility collected from PubMed and CNKI databases and mainly introduced acupuncture, moxibustion, and oral Chinese herbal medicine. In addition, we also briefly summarized psychological intervention, biosimilar electrical stimulation, homeopathy, hyperbaric oxygen therapy, etc.
... Acupuncture may have a potential therapeutic effect on thin endometrium in infertile women. Pulsatility index (PI) in the uterine arteries is considered valuable in assessing endometrial receptivity, and it was found to have decreased after EA treatment [24]. EA has been found to improve endometrial angiogenesis during periimplantation period by increasing the expression of VEGF R2/PI3K/AKT and VEGFR2/ERK signaling pathways in COH rats [25]. ...
Full-text available
Background Thin endometrium negatively impacts the reproductive function. Current treatments for thin endometrium do not always improve endometrial receptivity. Preliminary evidence suggests that electroacupuncture could have potential therapy for thin endometrium in infertile women. Thus, this randomized controlled trial was designed to test whether electroacupuncture can improve endometrial receptivity in infertile women with thin endometrium. Methods This study is a randomized, single-blinded, controlled, clinical trial. A total of 142 eligible patients will be recruited and randomly assigned to the electroacupuncture (EA) group or the sham electroacupuncture (SEA) group in a 1:1 ratio. Participants will receive 36 sessions over three menstrual cycles (12 weeks in total), with the same acupoint prescription. The primary outcome of this trial is endometrial thickness in the midluteal phase. The secondary outcomes include endometrial pattern, resistance index (RI) and pulsatility index (PI) of bilateral uterine artery and endometrium blood flow, serum estradiol (E2) and progesterone (P), and pregnancy rate. The pregnancy rate will be evaluated during a 6-month follow-up after completion of the trial. All other outcomes will be evaluated before treatment, during the treatment of 1st, 2nd, and 3rd menstrual cycle, and 6 months after treatment. Discussion If the outcome confirms the effectiveness of electroacupuncture for thin endometrium in infertile women, this treatment will be proposed for application in clinical practice. Trial registration Chinese Clinical Trials Registry ChiCTR2 000029983. Registered on 18 February 2020
While assisted reproductive technology has given so many people the ability to bear children, it is still far from a cure-all for fertility issues. Two traditional medical systems, traditional Chinese medicine (TCM) and Ayurveda have been using a very different, more holistic approach to help couples enhance fertility for millennia. This chapter explains how TCM and Ayurveda approach infertility issues. Specifically, it discusses the fundamental principles of both systems, the importance of focusing on foundation health and creating balance in the body, and how these systems personalize treatment. Both systems believe that proper preparation for pregnancy can set the stage for a healthier pregnancy and better long-term health for the future child. TCM refers to this as “tilling the soil before planting the seed.” The basic elements of diagnosis, patterns of imbalance, treatment approaches including acupuncture, herbal medicine, diet, panchakarma, and research on the efficacy of these approaches are discussed.
Background The effects of acupuncture on in-vitro fertilization outcomes remain controversial. This study aimed to perform a meta-analysis to assess the effectiveness of acupuncture as an adjuvant therapy to embryo transfer compared to sham-controls or no adjuvant therapy controls on improving pregnancy outcomes in women undergoing in-vitro fertilization. Methods A systematic literature search up to January 2021 was performed and 29 studies included 6623 individuals undergoing in-vitro fertilization at the baseline of the study; 3091 of them were using acupuncture as an adjuvant therapy to embryo transfer, 1559 of them were using sham-controls, and 1441 of them were using no adjuvant therapy controls. They reported a comparison between the effectiveness of acupuncture as an adjuvant therapy to embryo transfer compared to sham-controls or no adjuvant therapy controls on improving pregnancy outcomes in women undergoing in-vitro fertilization. Odds ratio (OR) with 95% confidence intervals (CIs) were calculated assessing the effectiveness of acupuncture as an adjuvant therapy to embryo transfer compared to sham-controls or no adjuvant therapy controls using the dichotomous method with a random or fixed-effect model. Results Significantly higher outcomes with acupuncture were observed in biochemical pregnancy (OR, 1.98; 95% CI, 1.55–2.53, p < 0.001); clinical pregnancy (OR, 1.70; 95% CI, 1.46–1.98, p < 0.001); ongoing pregnancy (OR, 1.78; 95% CI, 1.41–2.26, p < 0.001); and live birth (OR, 1.58; 95% CI, 1.15–2.18, p = 0.005) compared to no adjuvant therapy controls. However, no significant difference were found between acupuncture and no adjuvant therapy controls in miscarriage (OR, 0.96; 95% CI, 0.48–1.92, p = 0.91). No significant difference was observed with acupuncture in biochemical pregnancy (OR, 1.16; 95% CI, 0.65–2.08, p = 0.62); clinical pregnancy (OR, 1.13; 95% CI, 0.83–1.54, p = 0.43); ongoing pregnancy (OR, 1.04; 95% CI, 0.66–1.62, p = 0.87); live birth (OR, 1.02; 95% CI, 0.73–1.42, p = 0.90), and miscarriage (OR, 1.16; 95% CI, 0.86–1.55, p = 0.34) compared to sham-controls. Conclusions Using acupuncture as an adjuvant therapy to embryo transfer may improve the biochemical pregnancy, clinical pregnancy, ongoing pregnancy, and live birth outcomes compared to no adjuvant therapy controls. However, no significant difference was found between acupuncture as an adjuvant therapy to embryo transfer and sham-controls in any of the measured outcomes. This relationship forces us to recommend the use of acupuncture as adjuvant therapy in women undergoing in-vitro fertilization and inquire further studies comparing acupuncture and sham-controls to reach the best procedure.
Objective To explore the analgesic effects and uterine hemodynamics of perpendicular needling (PN) and transverse needling (TN) at SP 6 in patients with primary dysmenorrhea (PD). Methods In this randomized controlled trial, patients with PD diagnosed with cold-dampness congealing pattern were randomly assigned in a ratio of 1:1 to receive PN or TN at bilateral SP 6 for 10 min. Acupuncture was performed when the menstrual pain score was over 40 mm on the first day of menstruation, as measured using the visual analog scale for pain (VAS-P). The primary outcome was average menstrual pain (VAS-P). Secondary outcomes included the pulsatility index (PI), resistance index (RI), and systolic-diastolic peaks ratio (S/D) in uterine arteries as measured using color Doppler ultrasonography; anxiety as assessed using the Hamilton Anxiety Rating Scale (HAMA), blood pressure (BP), and heart rate (HR). Results Forty-eight patients completed the study. The TN group exhibited a significant reduction in VAS-P scores (–5.71 mm, 95% confidence interval (CI): –8.78, –2.63, P = .001), RI values (–0.05, 95% CI: –0.09, –0.01, P = .015), and HAMA values (–2.50, 95% CI: –4.78, –0.22, P = .032) when compared with the PN group. No significant differences in PI, S/D, BP, or HR values were observed between the two groups (P > .05). Conclusion TN at SP 6 was superior to PN in alleviating menstrual pain and anxiety in patients with PD. This analgesic effect of TN may be due to its better ability to improve uterine arterial blood flow via decreases in RI values.
Full-text available
Thirteen cycles of anovulation menstruation in 11 cases were treated with Electro-Acupuncture (EA) ovulation induction. In 6 of these cycles which showed ovulation, the hand skin temperature (HST) of these patients was increased after EA treatment. In the other 7 cycles ovulation was not induced. There were no regular changes in HST of 5 normal subjects. The level of radioimmunoreactive beta-endorphin (r beta-E) fluctuated, and returned to the preacupunctural level in 30 min. after withdrawal of needles in normal subjects. After EA, the level of blood r beta-E in cycles with ovulation declined or maintained the range of normal subjects. But the level of blood r beta-E in cycles in which the induction failed to cause ovulation was kept higher that that of normal. (P less than 0.05). There was a negative correlation in the decrease of blood r beta-E and increase of HST after EA (r = 0.677, P less than 0.01). EA is able to regulate the function of the hypothalamic-pituitary-ovarian axis. Since a good response is usually accompanied with the increase of HST, monitoring HST may provide a rough but simple method for predicting the curative effect of EA. The role of r beta-E in the mechanism of EA ovulation induction was discussed.
Objective To investigate the correlation between uterine artery impedance with immunohistochemical, histologic, and ultrasonographic markers of uterine receptivity. Design A prospective study of subfertile women undergoing a frozen embryo replacement cycle. Setting A tertiary infertility clinic. Patients The study was based on 86 patients who had failed to become pregnant during a standard IVF treatment cycle and who had at least two good quality embryos cryopreserved. Interventions All patients had pituitary desensitization with the GnRH analogue buserelin acetate, followed by E 2 and P replacement therapy. Vaginal color Doppler images of both uterine arteries were obtained on days 7, 14, and 21 of the first (trial) cycle. On day 21, an endometrial biopsy was taken for dating a 24-kd protein, placental protein 14, and E 2 receptor assessment. After a menstrual bleed had been induced, administration of estrogen and P was reinstituted and embryos transferred to the uterus on the 3rd or 4th day of P administration. Main Outcome Measures The mean pulsatility index of the left and right uterine arteries, a semiquantitative score of endometrial 24-kd protein, PP14, and E 2 receptor assessment, endometrial histologic dating, and pregnancy outcome. Results Nineteen of 76 patients who had a successful ET became pregnant. The pulsatility index on day 14 of both the trial and ET cycles was significantly lower in those who achieved pregnancy as compared with those who did not conceive: 2.65 (range 1.3 to 3.4) versus 3.85 (1.8 to 6.8) and 2.85 (1.4 to 3.6) versus 4.15 (2.1 to 6.8), respectively. There were significant correlations between pulsatility index and 24-kd protein, E 2 receptor, and endometrial histology but not with PP14 and endometrial thickness. Conclusions Uterine artery impedance has a significant correlation with biochemical markers of uterine receptivity and accurately predicts the probability of pregnancy in frozen embryo replacement cycles. It is a useful method for assessing uterine receptivity in assisted conception programs.
Following a complete gynecologic--endocrinologic workup, 45 infertile women suffering from oligoamenorrhea (n = 27) or luteal insufficiency (n = 18) were treated with auricular acupuncture. Results were compared to those of 45 women who received hormone treatment. Both groups were matched for age, duration of infertility, body mass index, previous pregnancies, menstrual cycle and tubal patency. Women treated with acupuncture had 22 pregnancies, 11 after acupuncture, four spontaneously, and seven after appropriate medication. Women treated with hormones had 20 pregnancies, five spontaneously, and 15 in response to therapy. Four women of each group had abortions. Endometriosis (normal menstrual cycles) was seen in 35% (38%) of the women of each group who failed to respond to therapy with pregnancy. Only 4% of the women who responded to acupuncture or hormone treatment with a pregnancy had endometriosis, and 7% had normal cycles. In addition, women who continued to be infertile after hormone therapy had higher body mass indices and testosterone values than the therapy responders from this group. Women who became pregnant after acupuncture suffered more often from menstrual abnormalities and luteal insufficiency with lower estrogen, thyrotropin (TSH) and dehydroepiandrosterone sulfate (DHEAS) concentrations than the women who achieved pregnancy after hormone treatment. Although the pregnancy rate was similar for both groups, eumenorrheic women treated with acupuncture had adnexitis, endometriosis, out-of-phase endometria and reduced postcoital tests more often than those receiving hormones. Twelve of the 27 women (44%) with menstrual irregularities remained infertile after therapy with acupuncture compared to 15 of the 27 (56%) controls treated with hormones, even though hormone disorders were more pronounced in the acupuncture group. Side-effects were observed only during hormone treatment. Various disorders of the autonomic nervous system normalized during acupuncture. Based on our data, auricular acupuncture seems to offer a valuable alternative therapy for female infertility due to hormone disorders.
In a previous study, prolonged low-frequency muscle stimulation in the hind leg of the fully conscious spontaneously hypertensive rat (SHR) was shown to induce a long-lasting reduction of blood pressure. It was also shown that opioid and serotonergic (5-HT) systems were involved. More recently, we have shown that the 5-HT1 receptors are involved in the post-stimulatory decrease in blood pressure. In the present study, the influence of this type of muscle stimulation on the pain threshold was investigated. Pain perception was measured as the squeak threshold to noxious electric pulses. After cessation of the stimulation, an analgesic response was elicited within 60 min and peak analgesia developed after 120 min, being 139 +/- 10% (P less than 0.01) of the prestimulatory control value. The increased pain threshold lasted for another 2 h. One group of SHR was pretreated with PCPA, a serotonin synthesis blocker, which completely abolished the post-stimulatory analgesia. To analyse further the involvement of different serotonin systems, drugs with selective affinity for 5-HT receptors were used. In one group a prestimulatory dose of metitepine maleate (a 5-HT1&2 receptor antagonist) abolished the post-stimulatory elevation of the pain threshold. The prolonged analgesic response was still present after prestimulatory treatment with ritanserin or ICS 205-930 (5-HT2 and 5-HT3 blocking agents respectively). In another group of experiments, the serotonin receptor antagonists were administered post-stimulation to animals with fully elicited analgesia. None of the antagonists used could reverse the elevation of pain threshold towards prestimulatory levels.(ABSTRACT TRUNCATED AT 250 WORDS)
Uterine arterial blood flow was studied at defined times during the ovarian or menstrual cycles. Transvaginal colour pulsed ultrasound was used to identify the vessels in 23 healthy women. Blood flow impedance as reflected by the pulsatility index (PI) was determined for both arteries on 132 occasions. There was no significant difference in the PI values between the right and left arteries. The average PI value was used for subsequent analysis (range 0.5-5.6; mean 2.8). Peak mean PI values occurred on day 1 of menses (4.6), the day of the plasma oestradiol peak (3.7) and the day of the LH peak plus 3 (2.9). The lowest mean PI values (indicating the least impedance to blood flow) occurred on the day of the LH peak minus 6 (2.6), and the day of the LH peak plus 9 (1.9). There are complex temporal relationships between uterine blood flow, ovarian morphology, the concentrations of plasma oestradiol and progesterone and the thickness of the endometrium.
The effect on blood flow of electro-acupuncture (EA) injection of substance P (SP) and calcitonin gene-related peptide (CGRP) was studied in musculocutaneous flaps in the rat, using laser Doppler flowmetry. The circulatory border was estimated before and after treatment. It was shown that treatment with EA increased the blood flow moving the circulatory border distally 66% after a treatment. Injection of NaCl into the dorsal central vein of the flap resulted in no increase in blood flow whereas SP 10(-9) M and CGRP 10(-9) M increased the blood flow so that the circulatory border moved distally 31% and 49%, respectively. It is suggested that the effect of EA on blood flow is similar to the effect achieved by injecting CGRP and SP.
In 45 women from an in vitro fertilization (IVF) program, the uterine and ovarian blood flows were investigated by vaginal Doppler sonography. The resistance index was used to evaluate the blood pattern. When comparing the patients who became pregnant after embryo transfer (ET [group I, n = 12]) with those who did not conceive (group II, n = 33), it is evident that in group I the vascular resistance of the uterine arteries is significantly lower on the day of follicular aspiration. No differences could be detected in the ovarian vessels. The data obtained so far suggest that the receptivity of the endometrium is a crucial factor for successful implantation. In the final analysis, this can be appraised not only on the basis of morphological but also of hemodynamic parameters.
There have been several causes of infertility attributed to gamete quality, congenital anatomical abnormalities and surgical complications. Published research into the reasons for failure of implantation of embryos has been confined to histochemical and histological studies of the endometrium. This paper presents preliminary data from an ongoing study to test the hypothesis that poor uterine perfusion is a cause of failure of implantation of embryos. It would follow that poor uterine perfusion is a cause of infertility. One-hundred-and-fifty-three patients who had been unsuccessful in conceiving despite three previous in-vitro fertilization attempts have been studied. Doppler ultrasound studies of the ascending branch of the uterine artery, during spontaneous ovarian cycles, revealed a poor mid-secretory uterine response in 48% of patients studied. Patients with poor mid-secretory uterine response were treated with orally administered hormone therapy to improve the mid-secretory uterine response prior to subsequent embryo replacement. The results of subsequent in-vitro fertilization therapy in patients with good uterine response and in women with improved uterine response after hormone therapy are presented. The numbers of patients in each group are insufficient for statistical analyses, but the trends observed support the hypothesis that poor uterine blood flow is a cause of infertility. Further evaluation is warranted.
Doppler studies of the uterine artery using an off-set Doppler transducer with a mechanical sector imaging transducer indicate clear changes in uterine perfusion during the ovarian cycle. In this study, 16 volunteers had Doppler studies performed at least twice weekly during spontaneous ovarian cycles. Endocrine assays were performed on each occasion to measure plasma oestradiol, progesterone and luteinizing hormone levels. Conventional criteria to assess uterine impedance using systolic/end diastolic ratio and Resistance Index were modified to obtain meaningful results and a new flow velocity wave form classification is presented. The results indicate increasing uterine perfusion with rising levels of plasma oestradiol and progesterone and a direct correlation with falling oestrogen levels in the follicular phase. We conclude that off-set mechanical sector duplex systems can be used effectively to monitor uterine responses to the hormone environment.