Acupuncture in Fertility and Sterility
In the last eight years, there have been fourteen studies published on acupuncture at the time of embryo transfer in the premier reproductive medicine journal, Fertility & Sterility. This specific acupuncture point technique is performed twice, once immediately before and again immediately after the embryos are placed inside the uterus. The majority of these trials have indicated acupuncture’s beneficial effects on pregnancy rates, and more research needs to be conducted to pinpoint how the acupuncture works during this procedure and if there is a particular group of patients who can benefit most. At this time it appears that women who are predicted to have a success rate with IVF over 50% receive less benefit while women who have a lower expected pregnancy rate received a significant benefit with acupuncture. Thus the patient population who has previously failed cycles or has age-related challenges is expected to benefit the most.
Acupuncture at Embryo Transfer has Significant Benefit on Pregnancy Rates
- Paulus W et al, Fertil Steril 2002 Vol 77, pg 721-724
- Magarelli P, Cridennda D, Fertil Steril 2004 Vol 81, Suppl 3, pgS20
- Quintero R et al, Fertil Steril 2004 Vol 81 Suppl 3, pg S11-12
- Smith C et al, Fertil Steril 2006 Vol 85, pg 1352-1358
- Westergaard L et al, Fertil Steril 2006 Vol 85, pg 1341-1346
- Dieterle S et al, Fertil Steril 2006 Vol 85, pg 1347-1351
- Benson M. R. et al, Fertil Steril 2006 Vol 86, Suppl 1 pg S135
- Udoff L. C. et al, Fertil Steril 2007 Vol 86, Suppl 1, pg S145
- Teshima D.R.K et al, Fertil Steril 2007 Vol 88, Suppl 1 pgS330
- Youran D et al, Fertil Steril 2008 Vol 90 Suppl 1, pg S240
Acupuncture at Embryo Transfer has no effect on Pregnancy Rates (but other + effects on stress, etc)
- Domar A etal, Fertil Steril 2006 Vol 86 Suppl 2, pg S379
- Domar A et al,k Fertil Steril 2009 Vol 91 pg 723-6
- Fratterelli FL et al Fertil Steril 2008 Vol 90 Suppl 1, pg S105
Acupuncture at Embryo Transfer has negative effect on Pregnancy Rates
- Craig L.B et al, Fertil Steril 2007 Vol 88, Suppl 1, pg S40 (These patients had to drive across busy traffic after getting acupuncture at an off-site clinic and it is difficult to distinguish which variable caused the negative effect on pregnancy rates.)
Acupuncture at Embryo Transfer in Other Journals
In these articles several questions are raised that future research needs to address. It is clear that placebo acupuncture needs to be standardized and a non-acupuncture control group should always be included. Also, since we are unclear on the specific mechanism of acupuncture, placebo needles which simply prick the skin but do not penetrate are assuredly causing at least some measurable effect as we see in one publication. Obvious to acupuncturists but not always to researchers, it matters very much which acupuncture points are used. It is of particular concern is the idea that “acupuncture” is either helpful or harmful when actually it is the correctly chosen points made by the practitioner which will determine the result. In some instances placebo acupuncture has referred to other acupuncture points not necessarily recommended for infertility. These random points would certainly have some effect on the body and cannot just be considered placebo. It is important to the future of acupuncture research that these questions are answered so that acupuncture studies can be compared and contrasted and held to higher standards. It is equally important to realize that acupuncture is an entirely different system of medicine that because of its holistic nature does not fit into the mold most research studies would need to make general conclusions.
The relationship between perceived stress, acupuncture, and pregnancy rates among IVF patients: A pilot study. Balk J et al, Complementary Therapies in Clinical Practice 2010, 16, 154-157 The patients who received acupuncture on the day of embryo transfer had a pregnancy rate of 55.6% compared with a control group who did not receive acupuncture rate of 35.5%.
Use of Acupuncture before and after embryo transfer. Dalton-Brewer N et al, Human Fertility 2010 Vol 12 No4, pg212-255
The acupuncture group had a positive pregnancy rate of 44.6% which was significantly higher than that of the control group who did not receive acupuncture. Further, the acupuncture seemed more beneficial to the women over 35 years of age.
Effects of Acupuncture on the pregnancy rate in embryo transfer and mechanisms: A randomized and controlled study. Zhang M et al, Chinese Acupuncture and Moxabustion 2003, Jan23 (1):3-5 Patients were in three groups; acupuncture, placebo and no acupuncture. The pregnancy rate was significantly higher in the group who received real acupuncture.
A randomized double blind comparison of real and placebo acupuncture in IVF treatment. So et al, Human Reproduction 2009 Feb;24(2):341-8 This article found no significant difference between placebo and regular acupuncture but did not have a non-acupuncture control group. Both placebo and acupuncture significantly increased blood flow and reduced anxiety.
Acupuncture and Blood Flow to Uterus and Ovaries
Over 15 years ago a study from Sweden showed that a specific electro-acupuncture treatment technique improved blood flow to the uterus and ovaries. This is particularly useful for women who have compromised blood flow due to age, stress or one of many infertility diagnoses. A series of these specific treatments are given during the 6-12 weeks leading up to IVF, IUI or a natural cycle. Several studies have since combined this treatment series with the embryo transfer treatments to see if the combination yielded even better results. Clinically, this is the preferred method of treating infertility with acupuncture. If a series of treatments begin early on, the patient will not only have better blood flow to the developing eggs and endometrial lining, but will feel more relaxed and decrease the negative physical effects of stress so they are better prepared for a healthy conception and pregnancy. Here you start to see the beginnings of the idea that acupuncture can assist the quality of the IVF cycle and not just be an adjunct treatment at embryo transfer.
Reduction of blood flow impedance in the uterine arteries of infertile women with electro-acupuncture. Stener-Victorin E, etal Human Reproduction 1996; 11:1314-1317. This study showed that after 8 specific acupuncture treatments blood flow through the uterine arteries was markedly increased and the beneficial effect lasted longer than 2 weeks.
Acupuncture & IVF Poor Responders: A Cure? Magarelli P, Cridennda D. Fertility & Sterility 2004;81 Suppl3, S20 This study combined both the blood flow protocol with the embryo transfer protocol and found that together they had a synergistic effect. The patients in this study had high FSH, poor sperm quality and previously failed IVF cycles earning them the title “poor responder”. The exciting part of this study was that it demonstrated that with the 2 combined protocols, “poor responders” achieved similar pregnancy rates to normal prognosis patients.
Changes in serum cortisol and prolactin associated with acupuncture during controlled ovarian hyperstimulation in women undergoing in vitro fertilization-embryo transfer treatment. Magarelli, PC, D Cridennda, M Cohen. Fertility & Sterility 2009 Dec;92(6):1870-9 In a group of women who did the series of acupuncture treatments to increase blood flow to the uterine arteries, a beneficial change in blood levels of stress hormones was measured and compared to the group who did not receive acupuncture. Cortisol and Prolactin levels normalized when they had been previously depressed by IVF drugs which has some implication for enhancing egg quality and implantation rates. The acupuncture group had significantly higher pregnancy and live birth rates.
A Randomized, controlled, double blind, cross-over study evaluating acupuncture as an adjunct to IVF. Quintero R et al, Fertility & Sterility 2004;81, Suppl 3, S11-12 A pilot study showed that a significantly lower amount of gonadotropins (IVF drugs) was used in women who combined IVF with acupuncture treatment. The acupuncture seemed to make the ovaries more responsive, a valuable benefit to women who produce a small number of eggs. This effect was probably due to the increase in blood flow to the ovaries but further research is needed.
Acupuncture and Stress in IVF Patients
It is widely accepted that infertility and the IVF process are extremely stressful events for couples wishing to achieve pregnancy. Recently, interest has turned toward looking at how high levels of stress may be negatively affecting IVF outcomes. While the exact mechanisms of acupuncture are still unclear, it has been demonstrated that acupuncture decreases sympathetic nervous system activity. This calming effect results in multiple physical changes in the body; changes in stress hormone levels, blood flow to the uterus and ovaries, better digestion and sleep cycles. What seem to be the most promising effects are improved response to IVF meds thereby reducing dose amounts, reduction in the number of treatment cycles needed to achieve pregnancy and reduction in the overall cost of IVF. Not to mention the reduction in anxiety and improved resilience of patients undergoing intense IVF treatments. These studies indicate that feeling more optimistic about a cycle can go a long way in the long term mental state of the couples involved.
The relationship between perceived stress, acupuncture, and pregnancy rates among IVF patients: A pilot study. Balk J et al, Complementary Therapies in Clinical Practice 2010, 16, 154-157 The patients who received acupuncture on the day of embryo transfer had a pregnancy rate of 55.6% compared with a control group who did not receive acupuncture rate of 35.5%. The patients who achieved pregnancy reported lower levels of stress before and after the embryo transfer than the control group.
Building resilience: An exploration of women’s perceptions of the use of acupuncture as an adjunct to IVF. De Lacey S, Smith C and Paterson C, BMC Complementary and Alternative Medicine 2009, 9:50 This study examined the use of acupuncture in women dealing with chronic health issues and how that may apply to IVF. The positive effects women experience point to a reduction in stress and suggest that it may in turn diminish the number of treatment cycles needed for pregnancy to occur.
The Impact of Acupuncture on in Vitro Fertilization Outcome. Domar A et al, Fertility & Sterility 2009 Vol 91 Issue 3 pg723-6 This publication examined the data collected on the subjective experience of receiving acupuncture during IVF. “Acupuncture patients reported significantly less anxiety post-transfer and reported feeling more optimistic about their cycle and enjoyed their sessions more than the control subjects.” Domar suggests that acupuncture may boost IVF success by improving the mental state at the time of embryo transfer.
An assessment of the demand and importance of acupuncture to patients of a fertility clinic during investigations and treatment. Hinks J and Coulson C, Human Fertility 2010 Vol 13 S1 Pg3-21 This study established that there is a clear demand for acupuncture and that it improved the general well being of women during infertility treatment. They concluded that patients who use acupuncture alongside IVF may persevere with ART increasing their ultimate chance of a successful pregnancy.
Stressful Life Events are Associated with a Poor In-vitro Fertilization (IVF) Outcome: A Prospective Study. Ebbesen S.M.S. Human Reproduction 2009;24(9):2173-2182 During 800 IVF cycles the authors found that the chance of success was related to chronic stress levels which seemed to have a negative effect on follicle development. Acupuncture reduces stress and this may be the mechanism by which it benefits IVF patients.
Acupuncture and Sperm
For many years publications have demonstrated acupuncture’s positive effect on sperm count, motility and morphology. Most trials included giving men a series of treatments, in most cases 10 treatments over the course of 5 weeks. Even though the outcomes of these studies are very promising, men are less likely to use acupuncture to improve their sperm parameters. This is due in large part to IVF clinics suggesting that ICSI or other ART circumvents the need for men to improve their sperm profile. Just recently the research is beginning to examine the DNA quality of the sperm in order to help reduce embryo fragmentation and improve embryo quality. Future studies should look for signs that acupuncture is improving the DNA integrity and not only increasing count or motility.
Effects of acupuncture on sperm parameters of males suffering from subfertility related to low sperm quality. Siterman S et al, Archives of Andrology 1997, Sep-Oct;39(2):155-61 When looking at infertile men, the acupuncture group receive significant improvements compared to the control group who did not receive acupuncture. In particular they saw improved motility and morphology.
Quantitative evaluation of spermatozoa ultrastructure after acupuncture treatment for idiopathic male infertility. Pei J etal, Fertility & Sterility 2005, Jul;84(1):141-7 In this study the acupuncture group showed a significant increase in the percentage and number of sperm with no structural defects. A general improvement in sperm quality, specifically the ultrastructural integrity of spermatozoa, was seen after acupuncture.
A prospective randomized placebo-controlled study of the effect of acupuncture in infertile patients with severe oligoasthenozoospermia. Dieterle et al, Fertility & Sterility 2009, Oct;92(4):1340-3 This small clinical trial demonstrated that the acupuncture group showed a significant increase in sperm motility after a series of acupuncture treatments.
Point and frequency specific response of the testicular artery to abdominal electroacupuncture in humans. Cakmak Y et al, Fertility & Sterility 2008;90:1732-8 The same techniques used to stimulate blood flow to the uterus and ovaries can also improve blood flow to the testicles. These authors indicate that an improvement in blood flow may address the damaged microcirculation associated with varicoceles and age.
Meta Analyses and Reviews
Effects of acupuncture on rates of pregnancy and live birth among women undergoing in vitro fertilization: systematic review and meta-analysis. Manheimer E et al, BMJ 2008;336 pg545-549 The British Medical Journal published a meta analysis of 7 of the acupuncture and IVF trials, choosing only those studies which met their strict criteria. The authors concluded, “The odds ratio of 1.65 suggests that acupuncture increased the odds of clinical pregnancy by 65% compared with the control groups… In absolute terms 10 patients would need to be treated with acupuncture to bring about one additional clinical pregnancy. These are clinically relevant benefits.” The accompanying editorial in the BMJ makes the comment that adding acupuncture to IVF improved pregnancy rates more than any other recent improvement or advance in IVF technology.
Acupuncture and assisted conception. Cheong Y et al, Cochrane Database of Systematic Reviews 2008, Issue 4. This group of researchers analyzed clinical trial data of acupuncture and IVF and concluded that acupuncture is a useful addition to IVF. This information was published as a Cochrane Review.
Acupncture and assisted conception. Cheong Y et al, Cochrane Database of Systematic Reviews 2009 Issue 1 A more recent version of this data base by the same authors concluded that these is an increase in live birth rate when acupuncture is performed on day of embryo transfer.
The Role of Acupuncture in the Management of Subfertility. Ng E H etal, Fertility & Sterility 2008, Jul;90(1):1-13 Another review of the literature from Hong Kong suggests that the positive effect of acupuncture in the treatment of infertility may be related to the central sympathetic inhibition by the endorphin system, the change in uterine blood flow and motility, and stress reduction.