Research and reviews
IVF clinics have improved their success rates steadily over the last decade or two. But in recent years these success rates have reached a plateau. Now that follicle stimulation, fertilization of eggs and embryo culture have been developed as far as current technology will allow, successful implantation of the embryo in the uterine lining is where improvement is needed to push success rates up again.
New developments in this area may be coming from an unexpected quarter. The last eight years have seen the publication in reputable medical journals, of the results of a number of clinical trials investigating the effect of acupuncture at the time of embryo transfer. Some of these trials have shown a significant increase in pregnancy rates when acupuncture is used and others have shown little effect. More research is needed in this area to discover if there is a particular group of women who do benefit from acupuncture on the day of embryo transfer. It appears that where the overall expectation of pregnancy is high (ie the control group rate was around 50% or more) then acupuncture performed on the day of embryo transfer confers no benefit. However where control group pregnancy rates were lower (around 30%) acupuncture appears to add a significant benefit. Hence many clinics recommend acupuncture to women who have had previous failed cycles or who are 35 or older.
Most scientists and clinicians would agree that this is still a controversial area and that more research needs to be done before acupuncture is generally accepted as an integral part of IVF treatment protocols. There is a compelling body of evidence however, of increased numbers of live births among IVF patients having acupuncture, and based on their own clinical experience, a number of IVF clinics in the United States consider acupuncture a standard component of care for their IVF patients.
The acupuncture IVF support clinic is actively involved in research projects in conjunction with IVF centres to examine the mechanism of acupuncture in increasing implantation and pregnancy rates.
Acupuncture and embryo transfer, Fertility and Sterility
Fertility and Sterility, the official publication of the American Society for Reproductive Medicine publishes juried original articles of scientific excellence in clinical and laboratory research relevant to reproductive endocrinology and physiology.
The studies below have all appeared in the journal Fertility and Sterility. Ten of them found that acupuncture performed close to the time of embryo transfer improved chances of pregnancy. Three reported no effect, and one found a negative effect (which was put down to the fact that the patients had to drive across town after their embryo transfer to reach the acupuncture clinic). More studies are underway to investigate the mechanism behind the effect of acupuncture on implantation of the embryo.
If any provisional conclusions are to be drawn at this stage, it is that acupuncture appears to confer an advantage to clinical trial groups which have an expected pregnancy rate of around 35% or less. Where chance of pregnancy is 50 - 60% then acupuncture applied at the time of embryo transfer may not offer so much benefit.
Acupuncture and embryo transfer, other publications
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Use of Acupuncture before and after embryo transfer Dalton-Brewer N et al, Hum Fert 2010 Vol 12 No 4 212 - 255 Human Fertility (abstracts from UK Fertility Societies Conference 2009) |
| This report describes outcomes for all patients who attended the The London Bridge Fertility, Gynaecology and Genetics Centre in London over a 2 year period and who had acupuncture . In the acupuncture group positive pregnancy rates/ET were 44.6% comparing favourably with the non-acupuncture historic control group. When they analysed outcomes in different age groups they discovered that acupuncture intervention was particularly effective in woman in the 35 - 39 and the over 40 group.
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Effect of acupuncture on the pregnancy rate in embryo transfer and mechanisms: A randomized and controlled study Zhang M et al, Chin Acup and Moxabustion 2003, Jan 23 (1): 3 - 5 Chinese Acupuncture and Moxabustion |
| 210 IVF patients were randomly placed in groups that received real acupuncture or placebo or no treatment on the day of embryo transfer. The pregnancy rate was significantly higher in the group who received real acupuncture. Additionally this trial showed that the women who received real acupuncture had fewer uterine contractions after the transfer.
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A randomized double blind comparison of real and placebo acupuncture in IVF treatment. So et al, Hum Reprod. 2009 Feb;24(2):341-8. Human Reproduction |
| Researchers in Hong Kong found no significant difference between the effects of placebo and regular acupuncture in clinical or ongoing pregnancy rates however on initial hCG testing the placebo group had more positive tests. Both placebo and regular acupuncture significantly increased blood flow to the uterus, reduced stress hormones and anxiety levels. These findings lead the researchers to suggest that placebo acupuncture is in fact not inert. Placebo acupuncture needles prick the skin at the acupuncture point but do not penetrate the skin. Many Japanese acupuncturists (who routinely use minimal stimulation of acupuncture points) would argue strongly that this is not an inert placebo procedure but a therapeutic one. Unfortunately there was no control group in this trial which received no acupuncture.
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The relationship between perceived stress, acupuncture, and pregnancy rates among IVF patients: A pilot study Balk J et al, Compl Therapies in Clinical Practice 2010,16,154–157 Complementary Therapies in Clinical Practice |
| These researchers at a university IVF clinic in Pittsburgh were interested to investigate the relationship between acupuncture, stress and pregnancy rates. The patients who received acupuncture on the day of embryo of transfer had a pregnancy rate of 55.6% compared with the control group pregnancy rate of 35.5%.
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Influence of Acupuncture on Infertility in Rats with Polycystic Ovarian Sydrome Zhang Wei Yi et al, Chinese Jnl Integrated Traditional and Western Med 2009 Nov (8), 973 Chinese Journal of Integrated Traditional and Western Medicine |
| This research carried out in Wuhan, China examined the effect of acupuncture administered to rats on various fertility measures including the implantation rate of blastocysts. Acupuncture was used on the abdomen and limbs. This significantly increased ovarian and uterine development and the rate of implantation of embryos compared to the control group of rats which did not have acupuncture. | |
Acupuncture and blood flow to uterus and ovaries
In addition to the acupuncture and embryo transfer studies there have been other clinical trials carried out which reveal information relevant to reproductive outcomes:
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Reduction of blood flow impedance in the uterine arteries of infertile women with electro-acupuncture. Stener-Victorin E, et al Hum Reprod 1996; 11:1314-1317. Human Reproduction |
| Many studies have shown that reduced blood flow in the uterine arteries is associated with a decreased pregnancy rate following IVF-embryo transfer. This study reported in Human Reproduction (the official journal of the European Society of Human Reproduction and Embryology) shows that after 8 acupuncture treatments blood flow to the uterus was markedly increased. Research carried out by one group of IVF clinics in California has shown that using this protocol to increase blood flow to the uterus, combined with acupuncture on the day of transfer has resulted in a markedly significant improvement in pregnancy rates.
See also:
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Ovarian blood flow responses to electro-acupuncture stimulation at different frequencies and intensities in anaesthetized rats Stener-Victorin E et al Autonomic Neuroscience Volume 108, Issues 1-2, 31 October 2003, Pages 50-5 Autonomic Neuroscience |
| The blood flow to the ovaries has also been shown to be enhanced by acupuncture by the same researchers. This study was done on anaesthetized rats, however we can assume a similar mechanism will operate in women.
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A Pilot Study Evaluating the Combination of Acupuncture with Sildenafil on Endometrial Thickness Yu W et.al.Presented at the Pacific Coast Reproductive Society Annual Conference 2007 |
| This small pilot study examined the effect of Viagra and acupuncture on the uterine linings of women who had a history of thin linings (<8mm) in previous IVF cycles (including patients who had previously used Viagra alone). They used the above mentioned protocols which improve blood flow to the ovaries and uterus. The researchers found that after acupuncture treatment the thickness of the lining improved to 10 mm or more in all participating patients.
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Acupuncture & IVF Poor Responders: A Cure? Magarelli P, Cridennda D. Fertil Steril, 2004;81(Supplement 3):S20 Fertility and Sterility |
| This clinical trial combined the acupuncture protocol used on the day of embryo transfer with the acupuncture treatment protocol designed to increase blood flow to the uterus. The authors report that “Significant increases in pregnancy outcomes were confirmed by this study which demonstrated that both acupuncture treatment protocols could be used together with a synergistic effect.” They add that “this study is the first to demonstrate that the use of acupuncture in patients with poor prognoses (elevated Peak FSH, longer history of infertility, poor sperm morphology) can achieve similar pregnancy rates to normal prognosis patients.”
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A randomized, controlled, double blind, cross-over study evaluating acupuncture as an adjunct to IVF. Quintero R et al, Fertil Steril, 2004;81(Supplement 3):S11-12 Fertility and Sterility |
| This pilot study showed that a significantly lower amount of gonadotropins (IVF drugs) was used when IVF was combined with standard acupuncture, ie the acupuncture appeared to make the ovaries more responsive to the drugs possibly due to increased blood supply to the ovaries. Increased ovarian responsiveness could be a useful effect for women who produce small numbers of eggs. This trial needs to be repeated with larger numbers of patients.
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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. Fertil Steril. 2009 Dec;92(6):1870-9 Fertility and Sterility |
| A number of women going through IVF were given acupuncture to increase blood flow through the uterine arteries in the immediate weeks before egg collection. The researchers found that the women who had acupuncture showed beneficial changes in serum levels of stress hormones compared to the control group of women who did not have acupuncture. The acupuncture treatments appear to normalize levels of cortisol and prolactin which have been artificially depressed by the IVF drugs. This may have implications for both egg quality and implantation. In addition the pregnancy and live birth rate was significantly higher in the acupuncture group.
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A randomized double blind comparison of real and placebo acupuncture in IVF treatment. So et al, Hum Reprod. 2009 Feb;24(2):341-8. Human Reproduction |
| This trial (also included above in the Embryo Transfer trials) examined the effect of acupuncture using real or placebo needles on blood flow to the lining of the uterus and found that when certain acupuncture points were stimulated whether by pricking or by penetration the blood flow increased significantly. | |
Acupuncture and sperm
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Quantitative evaluation of spermatozoa ultrastructure after acupuncture treatment for idiopathic male infertility. Pei J et al Fertil Steril. 2005 Jul;84(1):141-7 Fertility and Sterility |
| A group of infertile men who had pathological semen analyses according to WHO criteria, were treated with acupuncture twice a week for 5 weeks. A statistically significant increase after acupuncture in the percentage and number of sperm with no structural defects was demonstrated compared to the control group of patients who received no treatment. They concluded that male infertility patients could benefit from having acupuncture. A general improvement of sperm quality, specifically in the ultrastructural integrity of spermatozoa, was seen after acupuncture. | |
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Effect of acupuncture on sperm parameters of males suffering from subfertility related to low sperm quality. Siterman S et al Arch Androl. 1997 Sep-Oct;39(2):155-61 Archives of Andrology |
| A group of infertile men with abnormal semen analysis were randomly divided into 2 groups; one group was given 10 acupuncture treatments over 5 weeks, and the other group, no treatment. Significant improvements (p < 0.05) were demonstrated in the acupuncture group compared to the control group, in particular improved motility and morphology. | |
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Does acupuncture treatment affect sperm density in males with very low sperm count? A pilot study. Siterman S et al Andrologia. 2000 Jan;32(1):31-9. Andrologia |
| This pilot study once again showed a positive effect of acupuncture on sperm count - but this time on men with such low sperm counts (or no sperm) that they would usually require a testicular biopsy to extract sperm for use in an IVF cycle. Seven of the 15 men with no sperm at all produced sperm detectable by the light microscope after a course of 10 acupuncture treatments (p < 0.01) ie enough sperm could be produced for ICSI to be performed without recourse to testicular biopsy. The control group with similar semen analysis had no treatment and showed no change after 3 months. | |
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Effects of acupuncture and moxa treatment in patients with semen abnormalities. Gurfinkel E et al Asian J Androl. 2003 Dec;5(4):345-8. Asian Journal of Andrology |
| In a prospective, controlled and blind study, a group of infertile men (married for 3 - 11 years without children) were randomized into two groups, the treatment group receiving 10 acupuncture treatments and the control group receiving sham acupuncture treatments. The patients in the acupuncture group demonstrated a significant increase in the percentage of normal forms compared to the control group. | |
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Influence of acupuncture on idiopathic male infertility in assisted reproductive technology. Zhang M et al J Huazhong Univ Sci Tech Med Sci.2002;22(3):228-30 Journal of Huazhong University ( Abstract in Chinese) |
| This trial looks at sperm behaviour in an IVF setting. It was a “before and after” study involving 82 infertile men with pathological semen abnormalities and who’s sperm achieved a poor fertilization rate in at least 2 IVF/ICSI cycles. They were given acupuncture twice a week over 8 weeks and the IVF/ICSI cycles were repeated. The fertilization rates after acupuncture (66.2%) were significantly higher than that before treatment (40.2%) (P < 0.01). | |
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A prospective randomized placebo-controlled study of the effect of acupuncture in infertile patients with severe oligoasthenozoospermia Dieterle et al Fertil Steril 2009 Oct; 92 (4): 1340–3 Fertility and Sterility |
| This recent small clinical trial randomised 57 patients who had extremely low sperm counts, to acupuncture and placebo acupuncture groups. After receiving acupuncture twice weekly for 6 weeks motility of sperm (but not overall count) was found to increase significantly. The authors conclude that the results of the present study support the significance of acupuncture in male patients with severe oligoasthenozoospermia. More evidence with larger trials needs to be accumulated before the efficacy and effectiveness of acupuncture in male infertility can be evaluated. |
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Point- and frequency-specific response of the testicular artery to abdominal electroacupuncture in humans Cakmak Y et al, Fertil Steril 2008;90:1732–8 Fertility and Sterility |
| Just as electrocaupuncture can increase blood flow to the ovaries and uterus (see reports above) so it can to the testicles. These authors demonstrate that particular frequencies applied for just 5 minutes are effective in increasing blood flow in the testes, and suggest that such a stimulus may address the damaged microcirculation associated with varicoceles, and with aging. They note that decreased testicular arterial blood flow may result in impaired spermatogenesis from defective metabolism in the microcirculatory bed and suggest that further research is needed to discover if electroacupuncture can improve sperm manufacture in this instance. | |
Acupuncture and well being of IVF patients
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The Impact of Acupuncture on in Vitro Fertilization Outcome. Domar A et al Fertil Steril 2009 Vol 91 Issue 3 pg 723 - 6 Fertility and Sterility |
| One of the trials that investigated the effect of acupuncture on IVF pregnancy rates also collected data on the subjective experience of these women. The authors write “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”. Nobody knows how exactly acupuncture might boost IVF success, Domar said, although she suggests that it has something to do with a woman's mental state at the time of embryo transfer. |
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Understanding Women's views towards the use of Acupuncture while undergoing IVF treatment. Smith C and De Lacey S, 2008 In press FSA conference 2008 |
| This qualitative study found that most women who had acupuncture as an adjunct to IVF treatment reported increased well being, reduced anxiety and an increase in capacity to cope with the stresses of IVF and infertility treatments.
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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 BioMed Central |
| Resilience is an interesting and important concept when applied to couples doing IVF.
Studies of acupuncture involving women dealing with chronic health issues have shown that women experienced relief of presenting symptoms but also increases in energy, increase in relaxation and calmness, reduction in the reliance of prescription drugs (such as analgesics), quicker healing from surgery and increased self awareness and well being. Such effects indicate a reduction of stress that in turn may diminish the number of treatment cycles needed for pregnancy to occur. But further, reducing the number of cycles a woman must undertake to reach her goal of motherhood reduces the overall cost of IVF. |
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An assessment of the demand and importance of acupuncture to patients of a fertility clinic during investigations and treatment Hinks J and Coulson C, Hum Fert 2010 Vol 13, S1 Pg 3-21 Human Fertility |
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These authors working in a fertiiity clinic in the UK surveyed 200 patients who attended the clinic in August 2009. They discovered that there was a clear demand for acupuncture and that acupuncture may be valuable to improve the general wellbeing of women during infertility investigations and treatments. They also felt that patient resilience may be increased by the use of acupuncture alongside their IVF treatment such that patients would persevere with increased numbers of ART(Assisted Reproductive Technologies) cycles, thereby increasing their ultimate chance of a successful pregnancy. |
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A randomized double blind comparison of real and placebo acupuncture in IVF treatment. So et al, Hum Reprod. 2009 Feb;24(2):341-8. Human Reproduction |
| This paper which was included above amongst those describing the Embryo transfer trials, also investigated cortisol and anxiety levels before and after acupuncture was administered at precise points with either needles which penetrate the skin or "placebo" needles which prick the points but do not penetrate. No matter how the acupuncture was administered cortisol and perceived anxiety were significantly reduced after the treatment.
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The relationship between perceived stress, acupuncture, and pregnancy rates among IVF patients: A pilot study Balk J et al, Complementary Therapies in Clinical Practice, Online 24 December 2009 Complementary Therapies in Clinical Practice |
| These investigators aimed to determine if acupuncture affects the levels of perceived stress at the time of embryo transfer, and whether either acupuncture or changes in stress levels play a role in the success rate in IVF. The patients who received acupuncture in this study had both higher rates of pregnancy, and lower levels of stress both before and after embryo transfer. They postulated that reducing stress at the time of embryo transfer could result in less vasoconstriction and improved uterine receptivity. |
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Meta Analyses and Recent Reviews
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Effects of acupuncture on rates of pregnancy and live birth among women undergoing in vitro fertilisation: systematic review and meta-analysis. Manheimer E et al. BMJ 2008;336 pg 545-549 British Medical Journal |
| Early in 2008, the prestigious British Medical journal published its own analysis of the acupuncture in a meta analysis of 7 of these trials; ie they chose only those which met strict research criteria. The authors concluded,
And when they analysed the 4 trials that measured live births in addition to pregnancy rates, they found that acupuncture increased the odds by 91% and that the number of patients who would need to be treated to bring about an additional pregnancy dropped to 9. Impressive as these results are they may still be an underestimate, since the authors included women who’s IVF cycles were cancelled before transfer. 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. |
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Acupuncture and Assisted Conception Cheong Y et al, Cochrane Database of Systematic Reviews 2008, Issue 4. Cochrane Review |
| Another group of researchers have analysed updated clinical trial data and have come to the same conclusion as those who published the BMJ meta analysis, namely acupuncture is a useful addition to IVF. It has been published as a Cochrane Review. The Cochrane Collaboration is an international and independent organization dedicated to making up-to-date, accurate information about the effects of healthcare readily available worldwide.
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A Systematic Review and Meta -analysis of the effect of Acupuncture on Outcome of in Vitro Fertilisation Treatment El-Toukhy T et al BJOG 2008 115 (10); 1203 -13 British Journal of Obstetrics and Gynaecolgy |
| Another meta analysis also reported at an annual fertility conference indicated that in the trials they chose to include they found no effect of acupuncture on IVF treatment.This meta analysis included a trial which had been excluded from the previous analysis because it employed different methodology and therefore introduced a degree of heterogeneity which reduces the validity of this meta analysis.
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Traditional Chinese medicine and infertility. Huang, S T and Chen, A P C, Current Opinion in Obstetrics & Gynecology. 2008, 2(3):211-215. Current Opinion in Obstetrics & Gynecology |
| A recent review of current medical literature carried out by researchers in Taiwan noted that “traditional Chinese medicine could regulate the gonadotropin-releasing hormone to induce ovulation and improve the uterus blood flow and menstrual changes of endometrium. In addition, it also has impacts on patients with infertility resulting from polycystic ovarian syndrome, anxiety, stress and immunological disorders.” Their review concludes “Integrating the principles and knowledge from well characterized approaches and quality control of both traditional Chinese medicine and Western medical approaches should become a trend in existing clinical practice and serve as a better methodology for treating infertility.”
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The Role of Acupuncture in the Management of Subfertility Ng E H et al Fertil Steril. 2008 Jul;90(1):1-13. Fertility and Sterility |
| Another review of the literature from a group in Hong Kong concludes that the positive effect of acupuncture in the treatment of subfertility may be related to the central sympathetic inhibition by the endorphin system, the change in uterine blood flow and motility, and stress reduction.
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Acupuncture and assisted conception Cheong Y et al, Cochrane Database of Systematic Reviews 2009 Issue 1 Cochrane Database |
| A newer version of this data base by the same authors as the one listed above concluded that there is an increase in live birth rate when acupuncture is performed on day of embryo transfer.
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Acupuncture and herbal medicine in in vitro fertilisation: a review of the evidence for clinical practice Cheong Y et al, Hum Fert 2010, Vol. 13, No. 1, Pg 3-12. Human Fertility |
| A further analysis by the authors of the previously published Cochrane databases included more trials in their analysis of the benefit of acupuncture at embryo transfer. They included a trial which had previously been excluded due to the fact that its methodology introduced too much heterogeneity - this plus the inclusion of another trial which controversially used placebo acupuncture reduced the measurable benefits of acupuncture to IVF patients in this analysis.
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Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials Smith, GCS and J Pell BMJ 2003; 327, 1459 British Medical Journal |
| Finally, a tongue in cheek analysis of meta-analyses, randomised, placebo controlled trials and evidence based medicine. These authors very cleverly make a strong case for the fact that some interventions do NOT lend themselves to randomised blinded trials.But can still have a place in medicine simply because they have been seen to work. While not for a minute purporting to compare an acupuncture treatment to the life saving action of a parachute, we nevertheless would like to point out that there are some aspects of a discipline like acupuncture which will never be able to be squeezed onto the confines of a double blind randomised trial, without losing something of its essence. Other aspects of acupuncture, like some of its known physiological effects, can be measured in a trial setting - however the results of these trials should never be taken to be telling the WHOLE story! |
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