Around one in seven couples may have difficulty in conceiving which amounts to approximately 3.5 million people in the UK. Many of those couples turn to IVF (In vitro fertilisation) in order to get pregnant. The first baby in the world conceived as a result of IVF was born in the UK in 1978. Through over 30 years practice and research the use of IVF became common in the treatment of infertility. Although this technique is continuously developing, its success rate is still relatively low. For example, the overall live birth rate per embryo transfer has increased from 19.2% in 2002 to 23.3% in 2013. However, the result still falls short of the expectations of the infertile woman/couple. Furthermore, side effects from hormonal treatment are not without risk, such as over stimulated ovaries or psychiatric disorders.
Traditional Chinese medicine including both acupuncture and Chinese herbal medicine have been used to effectively treat infertility and improve success rate of IVF in China, and has been gradually increased its popularity in Western countries due to its synergetic effect with other therapies and little side-effect. During past 20 years increasing number of research studies were conducted to assess the effectiveness and mechanisms of acupuncture in enhancing IVF success rate. Here the recent development of acupuncture in improving success of IVF was summarized
The first report about acupuncture and IVF was published by Stener-Victorin and colleagues in 1999. The aim of the study was to evaluate the anaesthetic effect during oocyte aspiration. 150 women undergoing IVF were randomized to receive either electro-acupuncture or alfentanil. The result showed compared with the alfentanil group, the electro-acupuncture group had a significantly higher implantation rate, pregnancy rate, and take home baby rate. Paulus et al., (2002) reported that the use of body acupuncture and auricular acupuncture on the day of embryo transfer (ET) can increase IVF success rate. One-hundred sixty patients were randomly divided into an acupuncture group and a control group. Acupuncture and auricular acupuncture were administered 25 minutes before and after ET. The result showed that acupuncture group’s success rate was significantly higher than that of the control group. Since then, more randomised controlled clinical trials of acupuncture treatment in IVF, using similar acupuncture protocols to Paulus et al., (2002), have been conducted. For example, Dieterle et al., (2006) performed an acupuncture session 3 days after ET; while Westergaard et al., (2006) applied one additional acupuncture session 2 days after ET; and Smith et al., (2006) applied one more acupuncture session on day 9 of ovarian stimulation. Results from those studies showed that acupuncture treatment significantly improved the outcome of IVF. Zheng et al., (2012) conducted a systematic review and meta-analysis on this topic. 24 trials (a total of 5,807 participants) were included in this review. The results showed that acupuncture could improve clinical pregnancy rate and live birth rate among women undergoing IVF. Recent review study including 14 clinical trials (n = 3,971) found pooled benefit of acupuncture for IVF when performed at follicle phase and 25 min before and after ET, as well as 30 min after ET and implantation phase. However, acupuncture did not significantly improve the IVF clinical pregnancy rate when performed only at the time of ET (Shen et al., 2015).
However, other clinical trials showed different, negative results. El-Toukhy et al., (2010) reported that acupuncture performed at the time of ET did not improve the pregnancy or live birth outcome. The report by Craig et al., (2014) even showed that acupuncture performed off-site on the day of ET was detrimental to the success of the transfer. A systematic review and meta-analysis by El-Toukhy et al., (2008) in which 13 relevant clinical trials, including a total of 2500 women randomised to either an acupuncture group or a control group, showed that there was no sufficient evidence that acupuncture as adjuvant improved IVF clinical pregnancy rate compared with controls.
Why did these clinical trials show different results? It is likely that the different treatment protocols used in different studies resulted in different conclusions. For example:
1). Acupuncture treatment times were different: In El-Toukhy et al., (2008) report, acupuncture was performed around the time of egg collection (EC) in clinical 5 trials (n=877); however, acupuncture was performed around the time of ET in other 8 trials (n=1623).
2). Acupuncture techniques were different: acupuncture, electric acupuncture and auricular acupuncture were applied in different researches which had significant effect on the outcomes.
3). Acupoint selection and manipulation were different in each trial.
According to the theory of traditional Chinese medicine and knowledge accumulated by generations of practitioners in China, in order to enhance IVF success acupuncture treatment should follow those procedures:
1). Acupuncture starts once a week, 2 – 3 months before ovarian stimulation. This helps rebalance hormone levels and create a more receptive environment in the womb for conception. During this period of treatment some of the patients might get pregnant naturally.
2). During the ovarian stimulation acupuncture and herbs should be used to reduce the side effects caused by IVF drugs, and to improve response to hormonal stimulation.
3). One acupuncture session at an hour before EC helps to alleviate the tension and pain during EC.
4). Two sessions of acupuncture about an hour before and after ET will help calm the uterus to prepare for implantation.
5). Two sessions of acupuncture in the first week after ET will enhance uterus receptivity.
6). During pregnancy, acupuncture once a week until week 12 in order to maintain the pregnancy and prevent miscarriage.
Acupoint selection is another important factor which can influence the success of IVF. In many clinical trials, the acupoints Sanyinjiao (SP6) and Hegu (LI4) were selected after ET.
However, according to theory of traditional Chinese acupuncture these two acupoints are called “forbidden points” during pregnancy. A report by Liu (2007) showed that electric acupuncture applied on these acupoints can activate the myo-electrical activities of the uterine tract in both non-pregnant and pregnant rats, indicating the high risk of using acupoints LI4 and SP6 during pregnancy.
Outcome from acupuncture treatment in IVF mentioned above was mixed, depending on the treatment protocol design, acupoint selection and acupuncture techniques and manipulations. A standardized protocol with improved understanding of theory of traditional Chinese acupuncture should help enhance IVF success rate.
- Craig LB. Acupuncture performed before and after embryo transfer: a randomized controlled trial. J, Reprod. Med. 2014; 59(5-6): 313-20.
- Dieterle S. Effect of acupuncture on the outcome of in vitro fertilization and intracytoplasmic sperm injection: a randomized, prospective, controlled clinical study. Fertil Steril. 2006;85(5):1347-51.
- El-Toukhy. A new study of acupuncture in IVF: pointing in the right direction. Reprod. Biomed.Online. 2010; 21(3): 278-9.
- El-Toukhy. A systematic review and meta-analysis of acupuncture in in vitro fertilisation. BJOG. 2008; 115(10): 1203-13.
- Liu JL. Effect of electroacupuncture of different acupoints on myoelectrical activities of the uterus in rats. Zhen Ci Yan Jiu. 2007; 32 (4): 237-42.
- Paulus WE. Influence of acupuncture on the pregnancy rate in patients who undergo assisted reproduction therapy. Fertil Steril. 2002; 77 (4): 721-4.
- Shen C. The Role of Acupuncture in in vitro Fertilization: A Systematic Review and Meta-Analysis. Gynecol Obster Invest. 2015; 79 (1): 1-12.
- Smith C. Influence of acupuncture stimulation on pregnancy rates for women undergoing embryo transfer. Fertil Steril. 2006; 85(5): 1352-58.
- Stener-Victorin E. A prospective randomized study of electro-acupuncture versus alfentanil as anaesthesia during oocyte aspiration in in-vitro fertilization. Hum Reprod. 1999; 14(10):2480-4.
- Westergaard LG. Acupuncture on the day of embryo transfer significantly improves the reproductive outcome in infertile women: a prospective, randomized trial. Fertil Steril. 2006; 85(5):1341-46.
- Zheng CH. Effects of acupuncture on pregnancy rates in women undergoing in vitro fertilization: a systematic review and meta-analysis. Fertil Steril. 2012; 97(3):599-611.
- Grateful acknowledgements are due to Drs. Craig, Dieterle, El-Toukhy, Liu, Paulus, Shen, Smith, Stener-Victorin, Westergaard, Zheng and colleagues (This paper was based on their articles cited in above Reference section), as well as to Drs. Tiejun Tang and Bai-Yun Zeng for their work in preparing this briefing paper.