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Acupuncture and in vitro fertilization: Critique of the evidence and application to clinical practice


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Women undergoing in vitro fertilization (IVF) commonly use adjunctive therapies to improve IVF outcomes and reduce stress, anxiety and depression. Among these acupuncture is a popular choice. Despite 40 clinical trials and 9 systematic reviews investigating the efficacy of acupuncture for improving IVF outcomes, evidence-based guidelines are difficult to devise. The methodology used in the clinical trials does not closely resemble the use of acupuncture in real world acupuncture clinics, limiting the applicability of this research. Since many women undergoing IVF are currently using acupuncture there is a pressing need for a broader understanding of the use of acupuncture for female infertility. This paper offers a critical examination of the research on acupuncture and IVF and its limitations, details the differences between these studies and real world clinical practice, and discusses Chinese medicine theory for improving fertility and its possible scientific mechanisms within the context of clinical practice.
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Acupuncture and in vitro fertilization: Critique of the evidence and application to
clinical practice
Belinda Anderson
, Lara Rosenthal
Pacic College of Oriental Medicine, 915 Broadway, New York, NY 10010, USA
Rosenthal Acupuncture, 39 West 14th St., Suite 201, New York, NY 10011, USA
Chinese medicine
Evidence-based medicine
Female infertility
In vitro fertilization
Women undergoing in vitro fertilization (IVF) commonly use adjunctive therapies to improve IVF
outcomes and reduce stress, anxiety and depression. Among these acupuncture is a popular choice.
Despite 40 clinical trials and 9 systematic reviews investigating the efcacy of acupuncture for improving
IVF outcomes, evidence-based guidelines are difcult to devise. The methodology used in the clinical
trials does not closely resemble the use of acupuncture in real world acupuncture clinics, limiting the
applicability of this research. Since many women undergoing IVF are currently using acupuncture there is
a pressing need for a broader understanding of the use of acupuncture for female infertility. This paper
offers a critical examination of the research on acupuncture and IVF and its limitations, details the
differences between these studies and real world clinical practice, and discusses Chinese medicine theory
for improving fertility and its possible scientic mechanisms within the context of clinical practice.
Ó2012 Elsevier Ltd. All rights reserved.
1. Introduction
Infertility is a growing problem due to the choice to havechildren
later in life and the impact of environmental and lifestyle factors on
the both the female and male reproductive systems. Many perceive
in vitro fertilization (IVF) as the last remaining hope of being able to
achieve a successful pregnancy. However live birth rates from IVF
range from 31.9% for 35e37 year old women to 12.5% for 41e42 year
olds (for fresh non-donor egg;
rptCSR_PublicMultYear.aspx?ClinicPKID¼0). Consequently most
women need to undergo several IVF cycles to achieve a successful
pregnancy, and manywill not succeed without the use of donor eggs.
Due to the signicant emotional and nancial stress associated with
undergoing IVF many women seek out other therapies to reduce
stress levels and improve their IVF success rates. Acupuncture is
a common choice, partly because many randomized controlled trials
(RCTs) investigating the impact of acupuncture on IVF have been
undertaken. This data is accessible to patients and biomedical
practitioners and can be used as an endorsement for the use of
acupuncture to improve IVF success.
Close examination of the scientic evidence for the use of
acupuncture to improve IVF outcomes does not however lead to
simple conclusive statements. The inability to draw clear conclu-
sions about the efcacy of acupuncture for many conditions is
a pervasive problem in acupuncture research
for several reasons.
Firstly, many studies have consistently shown that placebo
acupuncture is not inert and does indeed have a therapeutically
benecial effect. Studies comparing verum (real) and placebo
acupuncture often show that both are equally as efcacious, but
more efcacious than no treatment or conventional treatment
Secondly, often in acupuncture RCTs the acupuncture intervention
is therapeutically suboptimal due to factors such as excluding the
use of Chinese medicine diagnosis, lack of individualized treat-
ments for subjects, and inadequate acupuncture dosage. Conse-
quently it becomes very difcult to demonstrate a statistically
signicant difference between a suboptimal verum intervention
and a therapeutically benecial placebo intervention. In the RCTs
investigating the impact of acupuncture on IVF outcomes this is
of several issues that render the research data difcult to
interpret and use for referral purposes and to apply to clinical
practice. This paper offers a critical examination of the research on
acupuncture and IVF and its limitations, details the differences
between these studies and real world clinical practice, and
discusses Chinese medicine theory for improving fertility and its
possible scientic mechanisms within the context of clinical
*Corresponding author. Pacic College of Oriental Medicine, 915 Broadway, New
York, NY 10010, USA. Tel.: þ1 212 982 3456x216; fax: þ1 212 982 6514.
E-mail addresses: (B. Anderson), lara@ (L. Rosenthal).
Tel.: þ1 212 807 6797.
Contents lists available at SciVerse ScienceDirect
Complementary Therapies in Clinical Practice
journal homepage:
1744-3881/$ esee front matter Ó2012 Elsevier Ltd. All rights reserved.
Complementary Therapies in Clinical Practice 19 (2013) 1e5
Author's personal copy
2. The research evidence
More than 40 clinical trials investigating the impact of
acupuncture on IVF outcomes have been undertaken since 1999,
and nine systematic reviews have been published in an attempt to
make general conclusions from the data.
From all this work the
evidence is still unclear about whether a women should have
acupuncture as an adjunctive therapy for IVF.
The simple
reasons why this evidence is inconclusive relate to issues like the
heterogeneity of the studies with regard to hypotheses, subject
populations, study protocols, acupuncture interventions, controls,
and outcome measures. The majority of the systematic reviews did
not take these factors into consideration and were not able to
demonstrate signicant benets of acupuncture for IVF.
However, the systematic reviews that accounted for some of
these issues in their statistical analysis methodology have
demonstrated a clinically benecial effect of acupuncture for
3. Limitations of the research
Despite the many discussions about the research into
acupuncture and IVF, there has been little critique of the
acupuncture protocols and dosage that were used in the RCTs.
is not uncommon in acupuncture research,
and reects the
possibility that acupuncture is often viewed as a standardized type
of intervention, where the protocol follows linear guidelines that
a trained clinician would recommend for the purposes of a clinical
trial. Most of the reviewers for the journals that publish these
studies and the biomedical readers are also largely unaware of how
acupuncture is practiced in real world settings. Consequently there
is an almost complete absence of appreciation that there are some
very signicant limitations in these trials related to the acupunc-
ture protocols and dosage.
3.1. Problem 1: lack of diagnosis & xed protocol bias
All of the acupuncture-IVF RCTs thus far have used the same
acupuncture points (a xed protocol) for all patients. In these
studies, an obese 35 year-old with polycystic ovarian syndrome
(PCOS) is given the same acupuncture protocol as a slender 42 year-
old with elevated follicle stimulating hormone (FSH) levels. This is
incongruent with a basic principle of Chinese medicine: that proper
diagnosis is the key to successful treatment. Most people outside
the eld of Chinese medicine do not realize that Chinese medicine
includes a complex diagnostic system, which determines
acupuncture point selection. To forgo diagnosis and use a xed
acupuncture protocol is somewhat analogous to an allopathic
physician treating everyone who complains of headaches with
Tylenol (acetaminophen).
Chinese medicine rests on the fundamental principle of indi-
vidualized treatments, whether this be acupuncture, Chinese herbs,
or any of the other acupuncture associated therapies.
Patients are
asked many questions about their main complaint and medical
history and this information is combined with several very specic
observations and palpation techniques to permit the practitioner to
formulate a diagnosis. The process of diagnosing is within the
context of Chinese medicine theory, which draws together many
different signs and symptoms to reach a summation of the overall
patient condition. Patients with the same Chinese medicine diag-
nosis may have many different biomedical diagnoses and clinical
presentations, and be treated differently in terms of acupuncture
point protocols and Chinese herbal medicine formulas. Conversely,
patients with the same biomedical diagnosis (e.g., PCOS, endome-
triosis, low ovarian reserve etc.) may have different Chinese
medicine diagnoses and would therefore receive different treat-
ments. It is the Chinese medicine diagnosis that determines correct
treatment, not the biomedical diagnosis. It is this aspect of Chinese
medicine that is least understood by other medical professionals
and the lay public. As with biomedicine, expert clinicians are often
revered for their capacity to accurately diagnose and select the
correct treatment.
It is difcult for an RCT to accommodate this aspect of Chinese
medicine. What happens in an RCT is that subjects are selected
according to a biomedical diagnostic category, in this case infer-
tility. Chinese medicine experts are asked to devise an acupuncture
protocol that would be approximately appropriate for the average
patient, which generally consists of the most commonly used
points. Indeed, some researchers have surveyed acupuncturists to
nd out what are the most commonly used acupuncture protocols
for infertility.
These average treatments are highly likely to give
suboptimal clinical outcomes because they are not devised specif-
ically for any of the subjects in the trial.
More recently new methodology for conducting acupuncture
RCTs has been developed using the Delphi approach.
In such trials
a panel of experts are asked to devise a ow chart of questions that
permit standardization of diagnostic methodology between
different acupuncturists. Acupuncture points that must be used for
each diagnostic category and additional optional acupuncture
points are stipulated allowing the acupuncturist to individualize
the treatment for each subject. None of the acupuncture-IVF RCTs
have used this improved methodology.
3.2. Problem 2: acupuncture dosage
The most commonly tested protocol for acupuncture-IVF RCTs is
the so called Paulus protocol, modeled on the protocol of Paulus
et al.
who demonstrated that subjects that received acupuncture
25 min before and after embryo transfer (ET) had clinical pregnancy
rates of 42.5% compared to the controls who did not receive
acupuncture and had rates of 26.3%. This protocol of acupuncture
25 min before and after ET became the accepted protocol for
acupuncture in an IVF cycle, and many women undergoing IVF
request just this and/or are recommended by fertility clinics to get
this treatment regime. Somehow this protocol, even though there
was only one successful RCTat the time, became the gold standard.
Even more surprising is the fact that many attempts to repeat this
outcome have not been successful.
Part of the reason for the inability to repeat this outcomes is
related to the fact that later studies included a placebo control and
could not demonstrate any statistical difference between the
verum and placebo treatments. As discussed earlier, placebo
acupuncture has been repeatedly shown to not be inert, making
these comparisons problematic.
However, other important
factors could account for this, including xed protocol bias (all
subjects receiving the same treatment, as discussed above) and
acupuncture dosage.
Acupuncture dosage consists of two components: the number of
points needled in a single treatment, and the total number of
treatments that the patient receives. Although it is possible for
patients to experience benecial effects from one or two treat-
ments and/or just the stimulation of one or two points, this is more
the exception, rather than the rule. The nature and duration of the
condition is a very signicant determining factor as to the likeli-
hood that just one or two treatments will be effective. Acute
conditions of short duration in younger patients are most likely to
respond to small dosages of acupuncture. Conversely chronic
conditions of long-term duration need larger dosages of acupunc-
ture, especially in patients with multiple health issues. Generally
speaking a clinically valid dosage of acupuncture usually includes
B. Anderson, L. Rosenthal / Complementary Therapies in Clinical Practice 19 (2013) 1e52
Author's personal copy
four to ten (or more) acupuncture points given in each of six (or
more) acupuncture treatments.
As mentioned, most acupuncture-IVF RCTs used two acupunc-
ture treatments e25 min before and after ET. Some of the RCTs did
add additional treatments, but most only included one or two
additional treatments within the IVF cycle. This is a very low dosage
of acupuncture. The number of points used in each treatment was
adequate, but the total number of treatments was sub-optimal.
What compounds this issue is the fact that infertility is a complex
medical issue, often associated with either signicant previous
gynecological issues/pathology (e.g., broids, endometriosis, fallo-
pian tube adhesions, autoimmune disease etc.) and/or with
patients whose age (often late 30s/early 40s) brings signicant
additional physiological challenges. It is therefore debatable
whether a couple of acupuncture treatments using xed protocols
will have a signicant impact on the outcome of an IVF cycle.
4. Mechanistic considerations
To be more realistic in our assessment and expectations of
acupuncture when used in conjunction with IVF we need to
consider possible mechanisms by which acupuncture could
improve IVF outcomes. Several have been proposed: improving
blood circulation to the ovaries and uterus; neuro-hormonal
modulation; cytokine modulation and improving implantation;
and reducing stress, anxiety and depression.
These mecha-
nisms can be thought of in terms of short-term and longer-term
benets, and correspondingly the likelihood to benet during
a single IVF cycle or more focused on longer-term benets for either
assisted or natural conception.
4.1. Treatment duration
Women that seek out acupuncture during IVF generally fall into
two categories: those that only seek treatment during an IVF cycle
(and often only receive something similar to the Paulus protocol e
25 min before and after ET); and those that seek out Chinese
medicine to help with infertility over a longer time period. In the
latter category acupuncture is used before,during, and between IVF
cycles to create an improvement in both reproductive and overall
health and thereby increase the likelihood that conception could
occur either naturally or through the use of assisted reproductive
technologies (ART).
4.2. Short-term treatment
Patients that receive a small number of treatments during an IVF
cycle are most likely beneting from acupuncture due to the
improved blood circulation to the uterus and ovaries, and
by facilitating lowered stress levels and improved relaxation.
This effect of acupuncture has been observed in several
However it is also possible that if women have
not had acupuncture before, the treatment could raise stress levels,
as was demonstrated in one clinical trial.
This is likely due to the
concern around an unknown procedure involving needles that is
likely to engender some degree of pain. So advising women to
receive acupuncture before and after ET should take into consid-
eration their perceptions about acupuncture and the possibility
that this may raise stress levels. From this perspective better advice
would seem to be suggesting acupuncture treatments before an IVF
cycle to determine if the patient is comfortable with the inter-
vention. In addition, the Paulus protocol model of using acupunc-
ture 25 min before and after ET may be introducing new stresses
that reduce efcacy. One study showed that when patients were
rushing through Seattle, WA, trafc trying to get their acupuncture
25 min before and after the ET, the pregnancy rates were lower
than without acupuncture.
Again from the perspective of
reducing stress levels and improving relaxation, this could be
Important additional short-term benets are to ameliorate the
side effects of IVF medications. Hormonal stimulation of the ovaries
to produce multiple follicles is often associated with signicant
abdominal bloating and discomfort. The associated increased
estrogen levels also often leads to uid retention, headaches, and
mood swings. A fundamental effect of acupuncture is to reduce
stagnation both energetically and in terms of facilitating the
reduction of uid, gas, and digestive accumulations. This impact
can bring signicant amelioration of IVF medication side effects
including ovarian hyperstimulation syndrome.
4.3. Longer-term treatment
Patients that seek out longer-term treatment often want to
improve their general state of health before starting IVF to increase
their chances of success and reduce the required number of IVF
cycles. Other patients begin by just seeking out acupuncture during
an IVF cycle (before and after ET) and nd that they notice benets
from it and then decide to continue regular treatment in subse-
quent IVF cycles and/or into their pregnancy. Some patients decide
to take breaks between IVF cycles and often will continue their
acupuncture treatments with the goal of improving their overall
and reproductive health to get ready for future IVF cycles or to try to
conceive naturally. In these longer treatment situations, a different
spectrum of mechanistic possibilities becomes evident.
Acupuncture treatment may be benecial for preexisting
gynecological conditions that can be a signicant factor preventing
conception or rendering patients ineligible for IVF. Patients and
biomedical practitioners are often unaware that acupuncture can
address a wide variety of gynecological conditions, an area very
well documented in the classical and modern Chinese medicine
Some examples of conditions that can be treated
with acupuncture and are commonly seen in women undergoing
IVF include: endometriosis, broids, PCOS, elevated FSH, adhesions,
and ovarian cysts. Acupuncture is unlikely to resolve advanced
cases of gynecological pathology where surgery may be necessary.
However, in such cases treatment can often alleviate symptoms,
work synergistically with biomedical treatments, and facilitate
successful conception. Mechanistic studies have demonstrated that
acupuncture can induce regular ovulation in women diagnosed
with PCOS
through modulation of endogenous regulatory
systems, including the sympathetic nervous system, the endocrine
system and the neuroendocrine system.
Patients receiving longer-term treatment also benet from the
effects of regular acupuncture on their other health issues. Chinese
medicine is holistic in the sense that treatment benets the whole
body and addresses all imbalances. This is why acupuncture clinical
trials that have included quality of life measurements often show
that patients receiving acupuncture experience a wide range of
benets and often have a general improvement in their feelings of
well being,
even if their main complaint did not signi-
cantly improve. This is attributable to the acupuncture treatment
and also to lifestyle modications that acupuncturists routinely
recommend. For fertility patients important lifestyle recommen-
dations often include dietary changes consistent with their Chinese
medicine diagnosis, increasing sleep duration and quality, nding
appropriate forms and intensity of exercise, incorporating relaxa-
tion techniques, and reducing excessive work hours.
Longer-term treatment also provides for signicant psycho-
emotional factors to come into play. Patients undergoing IVF are
faced with understanding a complex medical procedure with many
B. Anderson, L. Rosenthal / Complementary Therapies in Clinical Practice 19 (2013) 1e53
Author's personal copy
unknown outcomes. Patients are often very knowledgeable about
the process and experience considerable anxiety over their prog-
ress and its implications for their ability to conceive. Visiting their
acupuncturist at least once per week, and usually twice per week
during the stimulation phase and ET, provides an opportunity to
discuss progress, choices, and outcome possibilities with an expe-
rienced clinician who can provide emotional support and infor-
mation. For many women going through IVF, emotional endurance
and retaining a sense of hope are central to eventual success. Their
acupuncturist can become like a coach who partners with them
through the arduous journey. All of this reduces stress and imparts
all the physiological and psychological benets associated with
stress reduction.
5. Signicance of the research to clinical practice
Despite the fact that the Paulus protocol has been accepted as
the gold standard for acupuncture practice during an IVF cycle, we
really do not know if this is the most optimal approach to impart
short-term benets. What becomes especially difcult from
a practical standpoint in clinical practice is how critical it is for
treatments to be given 25 min before and after ET. This has never
been tested against any other time frame, leading many patients
to insist on trying to have acupuncture within this narrow time
frame and likely causing undue stress that could be counterpro-
ductive. For this reason, many acupuncturists will recommend
24 h before and after ET to facilitate scheduling and reduce stress.
If the primary short-term benets are to improve blood ow to
the reproductive system and reduce stress, then it would seem
logical that treatment throughout the entire cycle would also be
benecial, especially during the stimulation phase. Increased
blood circulation to the ovaries during hormonal stimulation
could potentially improve follicular development and reduce
medication side effects. For this reason acupuncturists may also
recommend a treatment 24 h before egg retrieval, and many
recommend twice weekly treatments during the whole IVF cycle
up until ET.
The question of whether acupuncture is more benecial if
undertaken for longer durations both before and throughout an IVF
cycle remains untested and unanswered. However many women
(and quite possibly the majority) who have acupuncture in
conjunction with IVF do more than just before and after ET. Most
common is acupuncture throughout the entire IVF cycle, often
twice per week, and then into pregnancy, or prior to and
throughout the next IVF cycle. Considering the possible mecha-
nisms by which acupuncture may benet women trying to
conceive (as discussed above), especially the modulation of
endogenous regulatory systems, a logical argument can be
proposed in support of the use of acupuncture before, during and
between IVF cycles. If circumstances permit it is most advisable to
start acupuncture (and Chinese herbal medicine) 3e6 months
before undergoing ART. This is discussed below in the section on
Chinese herbal medicine, which is often seen to signicantly
enhance the effect of acupuncture.
When acupuncture is performed throughout the entire IVF cycle
and into pregnancy, it is important to carefully consider using
acupuncture points that are contraindicated during pregnancy
following ET. This decision should be made based on the patients
Chinese medicine diagnosis. Many of the acupuncture-IVF RCTs
have included contraindicated points following ET.
One such trial,
showed that the group that received an additional acupuncture
treatment 2 days post ET
had a greater early pregnancy loss. This
is an aspect of the current research that requires further
6. Chinese herbal medicine
Chinese Herbal medicine is used extensively to treat a wide
range of gynecological conditions including both female and male
However there is relatively little research available
to make evidence informed decisions about the use of Chinese
herbal medicine for treating infertility. A recent systematic
investigating the effect of Chinese herbal medicine upon
pregnancy rates compared with ART intervention showed that
Chinese herbal medicine improved pregnancy rates 2-fold within
a 4 month period compared with fertility drug therapy or IVF. A
non-randomized trial
showed that the combination of Chinese
herbal medicine with intrauterine insemination (IUI) resulted in
statistically signicant higher pregnancy and live birth rates as
compared to IUI alone. A recent systematic review has also
demonstrated the effectiveness of Chinese herbal medicine for
Combining Chinese herbal medicine with fertility medications
must be done with caution because Chinese herbs can potentiate or
negate the effect of drugs,
and be potentially unsafe or detri-
mental. There are differing opinions within the Chinese medicine
community about the use of herbs together with IVF drugs. Some
advocate the use of Chinese herbs
while others recommend herbs
only during times when women are not taking any fertility medi-
cations (before starting IVF and between IVF cycles). Despite the
relatively small amount of evidence in support of the efcacy of
Chinese herbs for improving the success of ART, some additional
guidelines for clinical practice based on experience and mecha-
nistic considerations are given below.
When there is signicant preexisting gynecological pathology
and/or the patient is in her late thirties/early forties long-term
treatment with acupuncture and/or Chinese herbal medicine is
ideally at least 3e6 months. The 3e6 month duration has been
observed clinically to be the time required to see benecial
outcomes in terms of parameters such as better follicular response
to gonadotropin stimulation during IVF and signicant lowering of
FSH levels. The effect upon follicular response may be related to the
length of time it takes for a secondary follicle to develop into
a dominant follicle, which is approximately 3 months.
The 3e6
months of treatment may be undertaken before (if inclusive of
Chinese herbal medicine) or in conjunction with ART (if acupunc-
ture alone). Delaying ART to include Chinese herbal medicine
treatment needs to be carefully considered in relation to the age of
the patient and the potential disadvantages of delaying ART
Shorter duration treatment with Chinese herbal medicine can
also be quite effective, especially in cases of milder pathology of
recent onset. This is relevant for women who have breaks between
IVF cycles, which may be opportune times to take Chinese herbal
medicine. A common situation is where a woman has been through
one or more unsuccessful IVF cycles and then has elevated FSH,
such that she is not able to start another cycle. This provides an
opportunity to add Chinese herbal medicine to her treatment
regime, which is often more successful in reducing FSH levels than
acupuncture treatment alone. Women who have a history of
recurrent miscarriage following IVF also often benet from even
brief periods of Chinese herbal medicine treatment, which again is
usually better than acupuncture alone.
7. Conclusions
There is a pressing need for further research into the effective-
ness of acupuncture for improving IVF outcomes. Such research
needs to examine acupuncture treatment within a context that
more closely resembles real world clinical practice. Given that
B. Anderson, L. Rosenthal / Complementary Therapies in Clinical Practice 19 (2013) 1e54
Author's personal copy
many women undergoing IVF are utilizing acupuncture and
deriving benets in addition to improving IVF outcomes,
research does not adequately inform patients or clinicians. Possible
mechanisms by which acupuncture may treat gynecological
conditions requires further exploration, and may well represent
general mechanisms by which acupuncture modulates physiology
and treats a broad spectrum of pathology.
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B. Anderson, L. Rosenthal / Complementary Therapies in Clinical Practice 19 (2013) 1e55
... However, women undergoing IVF have complex conditions and most of their primary illnesses require long-term acupuncture treatment. Some reviews [19,20] suggested that during an ART cycle, the frequency, number of treatments, and timing of acupuncture were identified as important, at the same time, patients should start acupuncture treatment 3 to 6 months before IVF and receive >6 times treatments. Studies have shown that acupuncture treatment for 3 menstrual cycles can effectively improve the tolerance of the endometrium and create conditions for successful conception in women who have repeatedly failed to grow. ...
... Controlled clinical trial (all field) 19 16 confidence intervals (CIs). And for the continuous data, such as the number of retrieval eggs, blood hormone level, and so on, we expressed the results as the difference or standard mean difference (SWD) with 95% CI. ...
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Background: Previous studies have given an inaccurate assessment of the role of acupuncture in in vitro fertilization (IVF). We will use acupuncture doses as an entry point, discussing the dose-related effects of acupuncture therapy in women undergoing IVF. Methods: This study will search the following database: EMBASE, PubMed, Web of Science, the Cochrane Central Register of Controlled Trials (CENTRAL), and 4 Chinese databases. All databases will be searched from the date of database establishment to January 31, 2019. In addition, we will search possible studies which were included in previous meta-analyses. The primary outcomes are the clinical pregnancy rate (CPR) and the live birth rate (LBR). The secondary outcomes involved the biochemical pregnancy rate (BPR), the ongoing pregnancy rate (OPR), serum hormone level, the incidence of ovarian hyper-stimulation syndrome (OHSS), the cycle cancellation rates, and adverse events (AEs). After checking and integrating the raw data, we will use a 2-step to conduct the meta-analysis. Firstly, we will assess the effect of acupuncture on in vitro fertilization and embryo transfer (IVF-ET). Secondly, the meta-analysis will be performed for studies with similar total number of treatment sessions to investigate the dose-related effects of acupuncture. RevMan V.5.3 statistical software will be used for meta-analysis. If it is not appropriate for a meta-analysis, then a descriptive analysis will be conducted. Results: This study will investigate the relationship between pregnancy outcomes and the doses of acupuncture therapy in women undergoing IVF, and answer whether a higher-doses of acupuncture treatment will contribute to a better outcome of IVF-ET. Conclusion: The funding of this meta-analysis may provide convincing evidence for clinicians, benefitting more patients who crave children. Inplasy registration number: INPLASY202070072.
... Acute disorders of short duration in younger patients are most likely to respond to small dosages of acupuncture. Conversely chronic disorders of long-term duration in older patients need larger dosage of acupuncture [25]. Infertility is often associated with either significant previous gynecological issues (e.g., endometriosis, polycystic ovarian syndrome, and premature ovarian insufficiency) and/or with patients whose age (often late 30 s/early 40 s) brings significant additional physiological challenges. ...
... Some women only seek acupuncture treatment during an IVF cycle, and some receive the treatment before, during, and between IVF cycles. If the short-term treatment was beneficial for the reproductive system, it would be logical that the longer-term treatment throughout the entire IVF cycle or adding treatment before and between IVF cycles would also be beneficial [25]. It is noticeable that in Kong's program, the combination of traditional Chinese acupuncture and electroacupuncture, at least 12 times before ET, achieved a 81.8% success (twice the US average for IVF alone) [7], and in Magarelli's program that a total of 11 treatments resulted in 51% clinical pregnancy rate (37% for the control group). ...
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In vitro fertilization-embryo transfer (IVF-ET), a well-developed technology, provides the last possibility or hope for infertile women. However, the live birth rate per IVF cycle is still not satisfactory. Acupuncture is a frequently used adjunctive therapy drawing wide attention on improvement of IVF. Although so many randomized controlled trials have been evaluating the effect of acupuncture on IVF in the past 20 years, the exact efficacy of acupuncture on IVF is still controversy mainly because of no consensus on placebo control and acupuncture scheme. This paper focused on the general issues in clinical research of acupuncture and IVF and gave some suggestions for future directions.
... For the duration of three menstrual cycles of acupuncture, Zhuang et al. (20) found that CPR and EMT were improved significantly, while Shuai et al. (14) did not find out the same outcome in EMT. Furthermore, Belinda (21) confirmed that infertility is a complex medical issue, often associated with either significant previous gynecological issues/pathology and/or with advanced-age patients (>30 y or <40 y). Infertile women who receive longer-term treatment may benefit from the effects of regular acupuncture on their other health issues. ...
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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.
... [7,8] To diminish negative emotional symptoms and achieve higher pregnancy rates, many infertile women have been exploring alternative therapies and psychological interventions, including psychoanalytic interventions, relaxation, cognitive behavioral therapies, and online counseling. [9] Acupuncture is widely used in Eastern Asia as a key remedy for psychological problems. [10] Previous studies have reported that acupuncture is effective for improving emotional symptoms, including anxiety, [11] depression, [12,13] low self-efficacy, [14] and chronic mental stress, [15] which could indicate a therapeutic effect on improving emotional symptoms in infertile women. ...
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Background: Infertility causes emotional and psychological problems, including anxiety, depression, low self-efficacy, and chronic mental stress in women. These emotional problems can negatively affect fertility treatment. Numerous studies have reported the clinical therapeutic effects of acupuncture on emotional problems; however, the efficacy and safety of acupuncture treatment for emotional problems in infertile women remain unclear. This protocol aims to evaluate the efficacy and safety of acupuncture for treating emotional problems in infertile women. Methods: We will search the following databases from their inception to April 30, 2021: MEDLINE, EMBASE, Cochrane Library, Korean Medical Databases (KoreaMed, Korean studies Information Service System, Korean Traditional Knowledge Portal, Oriental Medicine Advanced Searching Integrated System, Research Information Sharing Service, and National Digital Science Library), and Chinese databases (CNKI and Wan Fang Database). We will include randomized controlled trials on acupuncture for emotional problems in infertile women. There will be no restrictions regarding language or publication date. The primary outcome will be assessed using an emotion-related assessment scale. The risk of bias of the included studies will be measured using the Cochrane risk of bias assessment tool. For meta-analysis, RevMan Version 5.4 software will be used to combine the relative risks for dichotomous outcomes, as well as the mean differences or standardized mean differences for continuous outcomes, with both having 95% confidence intervals. Results: Based on current evidence, this study will assess the effectiveness and safety of acupuncture for emotional problems in infertile women. Conclusion: This study will provide evidence for evaluating the acupuncture efficacy for infertile women with emotional problems. Registration number: INPLASY202150082.
... Retrospective reviews involving acupuncture and IVF seem to include the GV 20 point consistently, especially emphasizing its importance if utilized at least 24 hours before the FET. 20,21 Although some research has been conducted showing a downregulation of adrenal cortisol content and normalization of the HPA axis in depressed rats, thus, relieving symptoms of depression, there has been difficulty with replicating these findings. 22 In addition, similar research involving anxiety is not as readily available. ...
Background: Unexplained infertility is failure to conceive after 1 year in couples with normal semen samples and no abnormalities. Acupuncture to certain points along a meridian can affect the hypothalamic-pituitary-axis (HPA) by affecting the sensory nerve fibers, blood vasculature, and autonomic nervous system. GV 20, a point at the vertex of the head, is commonly utilized in acupuncture for infertility. Engagement of the HPA axis via GV 20 stimulation should always be considered when treating a woman, with a history of ovarian dysfunction and subsequent infertility, undergoing in vitro fertilization (IVF). This point, due to its systemic effects, should be considered prior to undergoing frozen embryo transfer (FET). Case: A patient was diagnosed with unexplained infertility when she underwent IVF and FET procedures. GV 20 stimulation helped this patient by improving her mood and ameliorating her psychiatric symptoms via suspected engagement of the HPA axis. Results: As of this writing, the patient has had a relatively uneventful, successful pregnancy and is currently at 28 weeks' gestation. The couple are happily expecting a baby boy. Conclusions: Practitioners should use GV 20 to address psychologic concerns, especially in patients seeking assistive reproductive technologies. The general sense of well-being induced by GV 20 stimulation involves engaging the HPA axis. More research on GV 20's effect on regulation of hormonal imbalances, mood, anxiety, and depression via the HPA axis is warranted as is research on how GV 20 stimulation affects prolactin levels when treating hyperprolactinemia, and subsequently, dopamine utilization.
Objective: Acupuncture has gained popularity among patients undergoing in vitro fertilization (IVF). However, the beneficial effect of acupuncture for improving IVF success is controversial and debatable. Given that different meta-analyses have come to different conclusions, it is crucial to explore the clinical trials in more detail. This literature review examined the limitation of randomized controlled trials (RCTs) on the influence of acupuncture in IVF. Methods: This review began with 844 studies. The inclusion criteria were studies that had acupuncture treatments in conjunction with IVF. After exclusion criteria were applied, the final number of peer-reviewed studies was 10. Results: There were substantial variations in the results of the 10 RCTs. This seemed to suggest that acupuncture was not effective in conjunction with IVF treatment. However, limitations emerged that might explain these variations in results. Such limitations include timing of acupuncture and point selections; acupuncture not performed by experienced licensed acupuncturists; lack of Traditional Chinese Medicine diagnoses and fixed protocols causing biases; acupuncture dosages; and using sham acupuncture as a control. Conclusions: There is an urgent need for further research into the effectiveness of acupuncture for improving IVF outcomes. This review provides insight into this complex and controversial topic, revealing limitations of the clinical trials that led to different conclusions. If future research can examine acupuncture treatment carefully to resemble real-world clinical practice-having appropriate controls and individualized acupuncture treatments-increasingly positive effects from acupuncture in IVF may be expected.
Maximising access to and the success of fertility treatments should be a priority for global reproductive health, as should overall patient well-being. The demand for in vitro fertilization (IVF) and other assisted fertility treatments has increased over the past decade and is likely to further increase in years to come. Nevertheless, there is still considerable unmet demand for infertility support worldwide. Moreover, the high emotional, physical and financial burden experienced by individuals undergoing IVF cycles can be a risk for their mental and physical health, which in turn can influence treatment continuation and the likelihood of IVF success. Studies from various parts of the world show that most individuals undergoing IVF also use adjunct alternative medicines and procedures, the most common being traditional Chinese medicine (TCM). The complementary and synergistic role of TCM for individuals undergoing IVF is an area that merits further attention and research, both for its potential positive effects on IVF success rates and for its broader physical and mental health benefits. However, much of the existing evidence is not sufficiently robust or consistent for findings to be adopted with confidence. This commentary argues that much work must be done to understand the efficacy and clinical best practices for these integrated approaches. This can be achieved in part by developing more robust and clinically relevant randomized controlled trial protocols, collecting and triangulating evidence through a variety of study designs and methods, and strengthening the collection and pooling of clinic-level data.
Introduction : Although effects of acupuncture on pregnancy outcomes among women undergoing in vitro fertilization (IVF) have been analyzed with systematic reviews and meta-analysis, few have been focused on psychological issues. The present systematic review and meta-analysis was designed to evaluate the efficacy of acupuncture on anxiety and/or depression relief during IVF treatment. Methods : As of November 2020, randomized controlled trials (RCTs) and quasi-RCTs to observe the therapeutic effects of acupuncture on anxiety and/or depression relief during IVF treatment were selected from the following databases: Pubmed, Embase, the Cochrane Library, Web of Science; China National Knowledge Infrastructure, Wanfang, VIP and Chinese Biomedicine database. Study selection, data collection and quality assessment were carried out. Study characteristics, result about anxiety and/or depression relief, IVF outcomes and adverse events were summarized. Meta-analysis was performed using Review Manager 5.3 software. Results : Twelve studies with 2867 participants were included. Significant difference (3 studies, 547 participants, MD -9.26, 95%CI −12.01 to -6.51, P<0.01) was observed in anxiety relief between acupuncture and control groups during IVF treatment. No significant difference (9 studies, 1896 participants, RR=1.30, 95%CI 1.03 to 1.64; P=0.02) was found for clinical pregnancy rate. Only 2 of 12 studies assessed remission of depression and showed inconsistent effects on depression relief of acupuncture. Conclusions : Acupuncture may have a positive effect on anxiety relief during IVF treatment, while the effect on depression relief is inconclusive. More standardized, large-size, randomized and multicenter studies should be carried out on whether acupuncture can alleviate the anxiety and/or depression during IVF treatment.
Overall research findings on the relationship between stress and infertility are inconsistent, marked by design flaws, and ultimately may only result in a minor delay in time to pregnancy but not in overall pregnancy chances. Although anecdotal data is widely shared, it appears that only anecdotes which support the relationship between stress and fertility are shared, thus creating a confirmation bias which likely supports what patients and others may want to believe: that we as human beings have a great deal of control over our fertility. It is likely the fear that we do not have control over our fertility and that fertility is inherently unfair, and not as easy as we would hope, results in the symptoms of anxiety and depression found among fertility patients. Further, for generations, women in particular have suffered in silence following infertility and miscarriage out of fear that they would be blamed by others for causing these outcomes by being too stressed. Given the psychological sequelae of infertility and fertility treatments, high-quality fertility care should include embedded mental health professionals trained in reproductive health to improve patient mood and coping, to improve the informed consent process, and to reduce premature treatment termination.
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Assisted reproductive technologies (ART) are increasingly utilised for resolving difficulties conceiving. These technologies are expensive to both the public purse and the individual consumers. Acupuncture is widely used as an adjunct to ART with indications that it may assist reducing the time to conception and increasing live birth rates. Heterogeneity is high between treatment protocols. The aim of this study was to examine what fertility acupuncturists consider key components of best practice acupuncture during an ART cycle, and to establish an acupuncture protocol by consensus. Fifteen international acupuncturists with extensive experience treating women during ART interventions participated in 3 rounds of Delphi questionnaires. The first round focused on identifying the parameters of acupuncture treatment as adjunct to ART, the second round evaluated statements derived from the earlier round, and the third evaluated specific parameters for a proposed trial protocol. Consensus was defined as greater than 80% agreement. Significant agreement was achieved on the parameters of best practice acupuncture, including an acupuncture protocol suitable for future research. Study participants confirmed the importance of needling aspects relating to the dose of acupuncture, the therapeutic relationship, tailoring treatment to the individual, and the role of co-interventions. From two rounds of the Delphi a consensus was achieved on seven treatment parameters for the design of the acupuncture treatment to be used in a clinical trial of acupuncture as an adjunct to ART. The treatment protocol includes the use of the traditional Chinese medicine acupuncture, use of manual acupuncture, a first treatment administered between day 6-8 of the stimulated ART cycle which is individualised to the participant, two treatments will be administered on the day of embryo transfer, and will include points SP8, SP10, LR3, ST29, CV4, and post transfer include: GV20, KD3, ST36, SP6, and PC6. Auricular points Shenmen and Zigong will be used. Practitioner intent or yi will be addressed in the treatment protocol. Despite a lack of homogeneity in the research and clinical literature on ART and acupuncture, a consensus amongst experts on key components of a best practice treatment protocol was possible. Such consensus offers guidance for further research.
The second edition of this popular text systematically addresses all aspects of treatment of infertility using Chinese medicine. Clinically focused and with a new easy-to-navigate design, the book begins by covering all the essential fundamentals you will need to understand and treat infertility, before going on to look at what Chinese medicine offers in the way of treatment for functional infertility in men and women, gynecological disorders which contribute to infertility and relevant lifestyle factors. Jane Lyttleton importantly devotes a large part of the book to discussing ways in which Chinese medicine and Western medicine might work together to overcome infertility, and details the increased experience over the past decade in working with IVF patients and their specialists. Leaps forward have also been made in the understanding of conditions such as Polycystic ovarian syndrome and immune infertility. New Features: Greatly expanded section on the place of Chinese medicine and IVF in treatment of infertility. New information on Polycystic ovarian disease and immune infertility and how Chinese medicine approaches their treatment. Updated and balanced advice on pre-conception care. Clinically focused, with easy-to-navigate design.
Thoroughly revised and now enhanced with color artwork, the new edition of this premier reference continues to offer the latest information on the diagnosis and management of reproductive endocrine disorders. National and international leaders from the field of reproductive endocrinology-including 30 new authors-equip you with coverage that encompasses the full spectrum of reproductive pathophysiology and disorders, from pregnancy and birth to reproductive aging. Full-color illustrations and new drawings provide a real-life depiction of basic cell structures and endocrine responses for a better understanding of the material, while new chapters explore the issues shaping today's practice. As an Expert Consult title, it includes convenient online access to the complete text of the book-fully searchable-along with all of the images, and references linked to Medline at the full spectrum of reproductive pathophysiology and disorders, from pregnancy and birth to reproductive aging. Includes the work of leaders in the field of reproductive endocrinology for guidance you can trust.Features anytime, anywhere online access to the complete text of the book-fully searchable-as well as all of the images, and references linked to Medline.Offers new content on preservation of fertility, endocrine disturbances affecting reproduction, imaging technologies, and adolescent reproductive endocrinology that explore the issues shaping today's practice.Includes full-color illustrations and new drawings which provide a real-life depiction of anatomy and cell function and dysfunction for a greater understanding.Provides a list of suggested readings at the end of each chapter for further reference. Presents fresh insights into today's field and future advances, as well as a greater international perspective.
Aim: To assess the effect of traditional Chinese medicine (TCM, acupuncture and medicinal herbs) as a therapeutic adjuvant to ovulation induction with intrauterine insemination (IUI) procedures and evaluate its contribution to pregnancy and "take-home baby" rates. Materials and methods: A comparative retrospective study was carried out in a university - affiliated municipal hospital. All women undergoing artificial insemination by donor spermatozoa (AID) and concomitantly treated with TCM were invited to participate. The enrolled women underwent weekly TCM in parallel with medical therapy. The treatment lasted between 2 and 36 cycles (equivalent to a time period ranging from one month to one year). The control group was comprised of women who underwent AID without TCM and whose data were retrospectively retrieved from hospital files. Pregnancy was assessed by human chorionic gonadotropin findings in blood 12-14 days after IUI. The birth rate was calculated during follow-up. Results: A total of 29 women aged 30-45 years were enrolled in the study. The historical control group included 94 women aged 28-46 years. Women who combined TCM with the procedures for undergoing IUI had significantly higher pregnancy (OR = 4.403, 95% CI 1.51-12.835, p = 0.007) and birth rates (OR = 3.905, 95% CI 1.321-11.549, p = 0.014) than the control group. Conclusions: TCM appears to be beneficial as an adjunctive treatment in IUI procedures. Randomized controlled trials are needed to further assess the role of acupuncture and herbs in this setting.