Acupuncture and IVF - support during fertility treatment
Many trying to conceive with assisted reproductive technology (ART) have also considered add-on therapies like acupuncture to support them throughout their cycle. Surveys suggest that up to half of ART patients report receiving acupuncture alongside their cycles. There are strong signals acupuncture provides significant benefits to fertility patients.
What is Acupuncture?
Acupuncture is a drug-free therapy that uses stainless-steel needles inserted at specific points on the body to promote self-healing and regulation. It is a therapy within the whole system of East Asian Medicine. Needles are strategically placed in acupuncture points to address qi, blood, yin, and yang and support one’s overall health and wellness. Qi is difficult to define because it is often translated with another term indicating the type of qi referenced and its functions. In simplest terms, qi is more than energy and is best defined as a transformative substance in constant motion. A more complex definition is needed, however. Qi may be better understood when one considers its functions: qi protects the body from infection, warms the body, transforms substances to support metabolic processes, moves substances throughout the body, and contains substances within the vessels, organs, and skin. [1] The combination of points needled can be different based on each patient’s individual needs. Historical texts identified acupuncture points appropriate for infertility as early as the 2nd century BCE. [2] We must acknowledge the cultural origins of acupuncture and the explanatory model of pathology and physiology put forth in East Asian Medicine upon which acupuncture theory is based.
How might acupuncture work?
The mechanisms explaining acupuncture’s effects are still being discovered, but we have research on animals and humans that demonstrates some specific effects that support fertility. Acupuncture has been found to increase blood flow to the reproductive organs. [3] It also induces the release of neurotransmitters that influence the hypothalamus-pituitary-ovarian axis and can support ovulation, menstrual regularity, and ultimately impact the overall ability to conceive. [4] We also know that acupuncture promotes the release of endorphins which help mitigate the stress response often accompanying infertility. [5] In some smaller studies, acupuncture addressed several features of Polycystic Ovarian Syndrome, like reducing elevated hormones (DHT, AMH) and improving insulin sensitivity. [6-9] Overall, these functions suggest acupuncture has tangible metabolic and physiological effects to support fertility.
How safe is acupuncture?
Acupuncture is a drug-free and generally safe therapy. The most common risks associated with acupuncture are mild (bleeding, bruising, mild pain). There is a minimal risk of pneumothorax, and its occurrence is rare [10], primarily when acupuncture is provided by a trained acupuncturist. Anyone eligible for ART is eligible for acupuncture.
How does acupuncture support me during ART?
At least 30 studies have investigated acupuncture’s impact on ART outcomes, and the results so far are confusing. Acupuncture provided small but significant effects in reducing IVF-related anxiety. (8 trials, 1,785 participants, SMD -0.21, 95% CI -0.39, -0.04). [11] In randomized trials when acupuncture was compared with no treatment, acupuncture significantly increased the chance of live birth by 32% (12 trials, 2,230 participants, RR=1.32, 95% CI 1.07 – 1.62) and significantly reduced the chance of miscarriage by about 43%. (10 trials, 2,042 participants, RR 1.43, 95% CI 1.03, 1.98). [12] However, when acupuncture was compared to another needling control like sham or placebo acupuncture, there was no difference detected between groups on live birth or miscarriage. [12,13] Acupuncture is effective in improving IVF birth outcomes but not efficacious.
So, acupuncture doesn’t work then, right? Before we conclude this, let’s consider the type of control methods used in acupuncture research. In trials, to reduce bias, it is crucial to randomize groups to either a treatment arm or a control arm and blind participants as to which group they are assigned. One way to blind the control group is to administer a “placebo” or “sham” treatment that looks and feels like the treatment group’s intervention but isn’t. The control should provide no treatment at all – like a sugar pill. In acupuncture trials, we have used needling controls like sham or placebo acupuncture that we thought looked and felt like the real thing and were inert. We have since learned that these techniques are not inert as initially intended. [14,15] The placebo or sham needles elicit more potent effects than other placebo controls and obscure any measurable benefit. [16] So, is this the best trial design when you compare acupuncture against a so-called placebo or sham acupuncture that is not inert? I would argue no. We clearly have a detectable benefit when acupuncture is added to the cycle and compared with no IVF alone on the outcomes of IVF live births, miscarriages, and IVF-related anxiety. We have yet to adequately assess efficacy.
How do I find a qualified fertility acupuncturist?
When looking for a fertility acupuncturist, you will want to ask a couple of questions.
How were you trained? The typical acupuncture training program is a 3-year master’s degree at minimum, sometimes four or more years. Some acupuncturists have a doctorate.
Are you board certified in acupuncture? The NCCA[o]M board certified acupuncturists so that they may get an acupuncture license in their state, except for the California Acupuncture Board, which uses its own certification exam. Board certification is key to knowing if your acupuncturist is adequately trained. Some continuing education programs are brief and unsupervised.
Have you worked with my condition before? This is a crucial question. Listen carefully to how they respond. You will want to ask how many cases like yours they have treated and what the outcomes were.
Have you done additional training in reproductive medicine and infertility? Look for another person if the person has only taken one training weekend. AB[o]RM board certifies fertility acupuncturists, and you can find one here. This certification is voluntary and doesn’t mean your acupuncturist is incapable of providing excellent care.
Have you ever collaborated with my doctor? (Assuming you are currently working with a doctor). Openness to collaboration is ideal if a relationship is not already well established.
If you are having trouble finding someone, email Dr. Lee Hullender Rubin. She will try to help connect you with someone in your local area.
References
1. Maciocia G. The Foundations of Chinese Medicine: A Comprehensive Text. 3rd ed. Edinburgh: Elsevier Churchill Livingstone; 2015.
2. Wu L, Wu Q, (trans.). Huang di Nei Jing; Yellow Emporer's Canon of Internal Medicine. San Francisco: China Science and Technology Press; 1997.
3. Stener-Victorin E, Waldenstrom U, Andersson SA, Wikland M. Reduction of blood flow impedance in the uterine arteries of infertile women with electro-acupuncture. Human Reproduction. 1996;11(6):1314-1317.
4. Stener-Victorin E, Wu X. Effects and mechanisms of acupuncture in the reproductive system. Auton Neurosci. 2010;157(1-2):46-51.
5. Han J-S. Acupuncture and endorphins. Neurosci Lett. 2004;361(1–3):258-261.
6. Leonhardt H, Hellstrom M, Gull B, et al. Serum anti-Mullerian hormone and ovarian morphology assessed by magnetic resonance imaging in response to acupuncture and exercise in women with polycystic ovary syndrome: secondary analyses of a randomized controlled trial. Acta Obstet Gynecol Scand. 2015;94(3):279-287.
7. Stener-Victorin E, Maliqueo M, Soligo M, et al. Changes in HbA1c and circulating and adipose tissue androgen levels in overweight-obese women with polycystic ovary syndrome in response to electroacupuncture. Obes Sci Pract. 2016;2(4):426-435.
8. Kokosar M, Benrick A, Perfilyev A, et al. A Single Bout of Electroacupuncture Remodels Epigenetic and Transcriptional Changes in Adipose Tissue in Polycystic Ovary Syndrome. Sci Rep. 2018;8(1):1878.
9. Stener-Victorin E. Hypothetical physiological and molecular basis for the effect of acupuncture in the treatment of polycystic ovary syndrome. Mol Cell Endocrinol. 2013;373(1-2):83-90.
10. Witt CM, Pach D, Brinkhaus B, et al. Safety of acupuncture: results of a prospective observational study with 229,230 patients and introduction of a medical information and consent form. Forsch Komplementmed. 2009;16(2):91-97.
11. Hullender Rubin L, Smith C, Schnyer R, Tahir P, Pasch L. Effect of acupuncture on IVF-related anxiety: a systematic review and meta-analysis. Repro Biomed Online. 2022.
12. Smith CA, Armour M, Shewamene Z, Tan HY, Norman RJ, Johnson NP. Acupuncture performed around the time of embryo transfer: a systematic review and meta-analysis. Reprod Biomed Online. 2019;38(3):364-379.
13. Xie ZY, Peng ZH, Yao B, et al. The effects of acupuncture on pregnancy outcomes of in vitro fertilization: a systematic review and meta-analysis. BMC Complement Altern Med. 2019;19(1):131.
14. Vickers AJ, Vertosick EA, Lewith G, et al. Acupuncture for Chronic Pain: Update of an Individual Patient Data Meta-Analysis. J Pain. 2018;19(5):455-474.
15. MacPherson H, Vertosick E, Lewith G, et al. Influence of control group on effect size in trials of acupuncture for chronic pain: a secondary analysis of an individual patient data meta-analysis. PLoS One. 2014;9(4):e93739.
16. Linde K, Niemann K, Meissner K. Are sham acupuncture interventions more effective than (other) placebos? A re-analysis of data from the Cochrane review on placebo effects. Forsch Komplementmed. 2010;17(5):259-264.
