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

The Dose-Related Efficacy of Acupuncture on Endometrial Receptivity in Infertile Women: A Systematic Review and Meta-Analysis

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.

Improving the health and treatment success rates of in vitro fertilization patients with traditional Chinese medicine: Need for more robust evidence and innovative approaches

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.

The Limitation of Randomized Control Trials on the Influence of Acupuncture and In Vitro Fertilization: A Literature Review

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.

Acupuncture treatment for emotional problems in infertile women: A protocol for systematic review and meta-analysis

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.

Pregnancy outcomes and the dose-related effects of acupuncture therapies in women undergoing in vitro fertilization: A protocol for systematic review and meta-analysis

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.

General Issues in Clinical Research of Acupuncture and In Vitro Fertilization

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.

GV 20's Role in In Vitro Fertilization and Frozen Embryo Transfer

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.

Effects of Acupuncture on the Outcomes of Assisted Reproductive Technology: An Overview of Systematic Reviews

Objectives

To conclude the evidence from systematic reviews (SRs) and meta-analyses assessing the effectiveness of acupuncture to treat couples with subfertility undergoing ART.

Methods

We searched the major databases from their inception to March 2018: PubMed, Embase, The Cochrane Library, China National Knowledge Infrastructure (CNKI), Wanfang Database, Chongqing VIP, and Sino-Med (the Chinese database). The primary outcomes of the overview were live birth and clinical pregnancy, and secondary outcomes were ongoing pregnancy, miscarriage, and adverse events. Study selection, quality assessment, and data extraction were performed independently by two review authors. Review methodological quality was assessed by using the AMSTAR tool, and the quality of the evidence was rated by GRADE methods.

Results

Eleven systematic reviews were included and published between 2009 and 2017. Our study showed that the acupuncture treatment seems to be a useful tool to improve the clinical pregnancy rate in patients who undergo assisted reproduction therapy. However, there was no evidence that acupuncture had any effect on live birth rate, ongoing pregnancy rates, or miscarriage regardless of whether acupuncture was performed around the time of oocyte retrieval or around the day of embryo transfer; this evidence is inconclusive because of the low quality of the included studies.

Conclusions

The evidence for acupuncture to treat couples with subfertility undergoing ART remains unclear. Further research is needed, with high-quality trials undertaken and reported.

Evaluation of "Energy Resonance by Cutaneous Stimulation" Among Women Treated by In Vitro Fertilization

OBJECTIVES

Pregnancy rate in in vitro fertilization (IVF) depends on many factors, such as the characteristics of the couple and the clinicobiological parameters. Interest in alternative and complementary medicine (ACM) for IVF is discussed because of the lack of scientific evidence. Energy resonance by cutaneous stimulation (ERCS), an acupuncture-like technique, consists of skin stimulation to transmit vibratory messages. The aim of this study was to evaluate the effect of ERCS on live birth rates (LBRs) in IVF.

DESIGN

A prospective observation study was performed in the Unit of Assisted Reproductive Technologies of a University Teaching Hospital. Every woman who agreed to participate in this study and received a fresh embryo transfer (ET) after IVF or Intracytoplasmic Sperm Injection (ICSI) was included. Patients randomly underwent an ERCS session on the day of ET according to the schedule of the midwife performing this technique. The control group consisted of women undergoing ET under usual conditions. The main outcome measure was the LBR per transfer.

RESULTS

Three-hundred-eighteen women were included, 120 in the ERCS + ET group and 198 in the ET without ERCS group. None of the women dropped out. The clinical characteristics in both groups were comparable. There was a significant difference in the clinical pregnancy rates, 31.7% in the ERCS group versus 21.7% in the No ERCS group (p = 0.037). The LBR in the ERCS group was nearly significantly higher, 29.2% versus 20.7% in the No ERCS group (p = 0,059).

CONCLUSIONS

Women undergoing ERCS on the day of ET had a significantly higher IVF pregnancy rate. However, this methodology made not possible to draw conclusions about the mechanisms that induced the increase of IVF LBRs: placebo effect, "cocooning," or ERCS self-effect? Further well-conducted studies are strongly needed to assess ERCS efficacy.

The Effect of Auriculotherapy on the Stress and the Outcomes of Assistant Reproductive Technologies in Infertile Women

Background:

Infertility means failure to achieve pregnancy after one year of regular unprotected sexual intercourse. Infertile women may experience severe stress and depression. Numerous studies have indicated that auriculotherapy could reduce stress. Thus, the aim of the present study was to determine the effect of auriculotherapy on the stress and the outcome assisted reproductive technology in infertile women.

Materials and Methods:

The present study was a clinical trial that was conducted on 56 infertile women aged 20–45, who were assigned into two groups of intervention and control, from November 2014 to November 2015. The control group only received the routine treatments, while the intervention group, in addition to their routine treatment, received auriculotherapy for 8–10 sessions during menstrual cycle. Both groups completed Newton's Fertility Problem Inventory in three stages. The datasets collected for the study were analyzed using independent t-test, repeated-measures analysis of variance, and Chi-square test.

Results:

The mean score of stress in the intervention group decreased significantly, compared to the control group prior to the embryo transfer and pregnancy test stages. Although insignificant, the rate of pregnancy in the intervention group was higher than the control group. There was a significant increase in the rate of clinical pregnancy in the intervention group, compared to the control.

Conclusions:

The results indicated that auriculotherapy might be effective in reducing stress and improving the outcome of assisted reproductive treatment.

Effectiveness of Acupuncture in Women with Polycystic Ovarian Syndrome Undergoing in Vitro Fertilisation Or Intracytoplasmic Sperm Injection: A Systematic Review and Meta-Analysis

Objectives

The aim of this systematic review was to assess the evidence from randomised controlled trials (RCTs) on the efficacy, effectiveness and safety of acupuncture in women with polycystic ovarian syndrome (PCOS) undergoing in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI).

Methods

We searched a total of 15 databases through October 2015. The participants were women with PCOS (diagnosed using the Rotterdam criteria) undergoing IVF or ICSI. Eligible trials were those with intervention groups receiving manual acupuncture (MA) or electroacupuncture (EA), and control groups receiving sham acupuncture, no treatment or other treatments. Outcomes included the clinical pregnancy rate (CPR), live birth rate (LBR), ongoing pregnancy rate (OPR) and incidence of ovarian hyperstimulation syndrome (OHSS) and adverse events (AEs). For statistical pooling, the risk ratio (RR) and its 95% (confidence interval) CI was calculated using a random effects model.

Results

Four RCTs including 430 participants were selected. All trials compared acupuncture (MA/EA) against no treatment. Acupuncture significantly increased the CPR (RR 1.33, 95% CI 1.03 to 1.71) and OPR (RR 2.03, 95% CI 1.08 to 3.81) and decreased the risk of OHSS (RR 0.63, 95% CI 0.42 to 0.94); however, there was no significant difference in the LBR (RR 1.61, 95% CI 0.73 to 3.58). None of the RCTs reported on AEs.

Conclusions

Acupuncture may increase the CPR and OPR and decrease the risk of OHSS in women with PCOS undergoing IVF or ICSI. Further studies are needed to confirm the efficacy and safety of acupuncture as an adjunct to assisted reproductive technology in this particular population.

Faculty survey to assess research literacy and evidence-informed practice interest and support at Pacific College of Oriental Medicine

CONTEXT

Educating healthcare practitioners to understand, critically evaluate, and apply evidence to the clinical practice of complementary and alternative medicine has been an important initiative for the National Institutes of Health National Center for Complementary and Alternative Medicine.

OBJECTIVE

To determine the self-assessed research skills and interest of faculty at Pacific College of Oriental Medicine (New York campus) and their likely support of, and participatory interest in, an evidence-based medicine (EBM) training program.

DESIGN

The survey was administered in Survey Monkey. All questions were close-ended with 5-point Likert answers, except for one open-ended question at the end of the survey.

SETTING

One of three campuses of Pacific College of Oriental Medicine (PCOM), the largest Chinese medicine college in the United States.

PARTICIPANTS

102 faculty employed at PCOM.

RESULTS

The response rate was 88.7%. Responses illustrated a generally high degree of interest and support for research, EBM, and institutional participation in research activities. Faculty who responded to the open-ended question (19.6% of respondents) expressed concerns about the relevance of research to Chinese medicine and the possibility of co-option by biomedicine.

CONCLUSIONS

While faculty were overall supportive and interested in research and EBM, the results are consistent with the hypothesis that success of EBM training programs could be enhanced by soliciting and addressing faculty concerns and by being inclusive of approaches that honor the traditions of Chinese medicine and its own forms of clinical evidence.

Acupuncture and women's health: an overview of the role of acupuncture and its clinical management in women's reproductive health

BACKGROUND

Acupuncture and other modalities of Chinese/East Asian medicine have been used to treat women's health for many centuries. Gynecology specialties focus particularly on menstrual and reproductive disorders. Both the adoption of the use of acupuncture outside Asia, and the incorporation of scientific analysis in Asia have challenged biomedical conceptions of what can be achieved with this treatment method. The scale of research activity in relation to acupuncture and women's health has increased over the last 20 years.

OBJECTIVE

This review aims to explore the research evidence in relation to acupuncture use for women's reproductive disorders, focusing on both clinical findings and experimental research on acupuncture's mechanisms of action in relation to women's health.

METHODS

A narrative literature search was undertaken using searches of electronic databases and manual searches of journals and textbooks. The search included all literature published prior to June 2013. The literature was assessed as to the nature of the study it was reporting and findings synthesized into a commentary.

RESULTS

For acupuncture's mechanism of action the search resulted in 114 relevant documents; in relation to clinical reports on the use of acupuncture for women's health 204 documents were found and assessed.

CONCLUSION

There is preliminary data indicating acupuncture may improve menstrual health and coping for women experiencing delays falling pregnant. There is experimental data showing that acupuncture can influence female reproductive functioning, although the actual mechanisms involved are not yet clarified. Further well-conducted clinical research would benefit our understanding of the usefulness of acupuncture to women's health.