Can Acupuncture help to increase the success rate of IVF?

Tiejun Tang

Around one in seven couples may have difficulty conceiving. This 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 still relatively low. According to NHS statistics in 2010 the IVF success rate in UK was:   
     32.2% for women under 35 
     27.7% for women aged 35-37 
     20.8% for women aged 38-39
    13.6% for women aged 40-42
         5% for women aged 43-44 
      1.9% for women aged over 44

How can the success rate of IVF be increased?  At least two options spring to mind.

Firstly, the patient should choose a good hospital or clinic, which has a long history of infertility treatment with IVF. Many of my clients have successfully become pregnant by using the services at the Centre for Reproductive and Genetic Health (CRGH), the IVF Clinic ARGC and University College London Hospital (UCH) in central London.

The second option is TCM (traditional Chinese medicine), including both acupuncture and Chinese herbal medicine.

Is it necessary to use acupuncture or Chinese herbs during the IVF? Does acupuncture really works or is it just a placebo? Patients often feel confused by the number of differing opinions. After a review of some research reports, the right answer should emerge.

The first report about acupuncture and IVF was published by Stener-Victorin^[1]  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^[2] (2002) reported that the use of body acupuncture and auricular acupuncture on the day of embryo transfer (ET), can increase IVF success rate. 160 patients were randomized, grouping them 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. More randomised controlled clinical trials have been carried out since then. Some studies used similar acupuncture protocol to Paulus; Dieterle^[3] did another session 3 days after ET; Westergaard^[4] did one additional session 2 days after ET; and Smith^[5] did one more session on day 9 of ovarian stimulation. Zheng^[6] did a systematic review and meta-analysis on this topic. 24 trials (a total of 5,807 participants) were included in this review. The result showed that acupuncture could improve clinical pregnancy rate and live birth rate among women undergoing IVF.

However, some clinical trials showed different, negative results. El-Toukhy^[7] reported acupuncture performed at the time of ET does not improve the pregnancy or live birth outcome. The Craig^[8] report even showed that acupuncture performed off-site on the day of ET was detrimental to the success of the transfer. El-Toukhy^[9] also did a systematic review and meta-analysis in which 13 relevant trials, including a total of 2500 women randomised to either an acupuncture group or a control group, were identified. The result showed that there is not sufficient evidence that adjuvant acupuncture improves IVF clinical pregnancy rate.

On 10^th March 2010 British Fertility Society (BFS) issues new guidelines on the use of acupuncture and Chinese herbal medicine in fertility treatment. The guidelines found that there is currently no evidence that having acupuncture or Chinese herbal medicine treatment around the time of assisted conception increases the likelihood of subsequent pregnancy.

Why did these clinical trials show different results? My opinion is that the different treatment protocol resulted in different conclusions.

Acupuncture protocols are different in fowling aspects:

1)The treatment times were different: In El-Toukhy’s^[7] report, 5 trials (n=877) acupuncture was performed around the time of egg collection (EC), 8 trials (n=1623) acupuncture was performed around the time of ET. Some reports maybe add 1 or 2 sessions after or before the day of ET.  

2) The acupuncture techniques were different: acupuncture, electric acupuncture and auricular acupuncture were applied in different research.

3)   The acupuncture point selection and manipulation were different in each trial.

4)   Most report only the use acupuncture, no herbs were involved.

The use of Traditional Chinese acupuncture to treat infertility has a long history. The first classic of acupuncture points HuangDi MingTang Jing (黄帝明堂经) (BC138-AD106) recorded 43 acupuncture points which were used to treat gynaecological diseases including Juezi (绝子, infertility). TCM believes fertility function was dominated by kidney. In females it has a close relation with qi and blood, and the function of the Chong and Ren meridians. Some acupuncture points and herbs can regulate the function of Chong and Ren, tonify the kidney and thereby improve fertility. Traditional Chinese acupuncture is often combined with Chinese herbal medicine. Recently Ried^[10] reported that Chinese herbal medicine can improve pregnancy rates 2-fold within a 3-6 month period compared with Western medical fertility drug therapy. The effect of needles and herbs might enhance each other.

A good protocol of IVF treatment in Chinese acupuncture should be: 

• 2 - 3 months before ovarian stimulation the patient should start acupuncture once a week. This treatment can balance hormone levels and create a more receptive environment in the womb for conception. During this period of treatment some of patients might get pregnant naturally.
• During the ovarian stimulation acupuncture and herbs should be used to reduce the side effects caused by IVF drugs, improve response to hormonal stimulation.
• One acupuncture session at an hour before EC, to alleviate the tension and pain during EC.
• Two sessions of acupuncture about an hour before and after ET. Calm the uterus to prepare for implantation.
• Two sessions of acupuncture in the first week after ET
• During pregnancy, acupuncture once a week until week 12 in order to maintain the pregnancy and prevent miscarriage.

Treatment with acupuncture could be likened to the use of Western medical drugs: if used incorrectly, they will be ineffectual. For instance, if an antibiotic were taken by the patient in a much lesser dose or finished earlier than directed, the drug may not have the desired therapeutic effect. The same can be said of acupuncture treatment.

The most recent study^[11] showed that acupuncture did not significantly improve the IVF clinical pregnancy rate when performed only at the time of ET. However, it was found that there was a pooled benefit for IVF when acupuncture was performed at the follicle phase and 25 min before ET, as well as 30 min after ET and at the implantation phase.

Acupuncture point 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. According to Chinese traditional acupuncture theory these two are “forbidden points” during pregnancy. Although there have been some differing opinions regarding to these two forbidden points in acupuncture history, a research paper by Liu^[12]  showed that electric acupuncture on these points can activate the myoelectrical activities of the uterine tract in both non-pregnant and pregnant rats. I think these two points should be avoided after ET, in order to minimise the risk of miscarriage.

TCM can increase success rate of IVF in varying degrees. The significance of this influence will depend on the treatment protocol, point selection and manipulations. Correct treatment can provide the best conditions for effective results.

References :

1.  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.
2. Paulus WE. Influence of acupuncture on the pregnancy rate in patients who undergo assisted reproduction therapy. Fertil Steril. 2002; 77 (4): 721-4
3.  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.
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.
5.  Smith C. Influence of acupuncture stimulation on pregnancy rates for women undergoing embryo transfer. Fertil Steril. 2006; 85(5): 1352-58.
6.  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. 
7. El-Toukhy. A new study of acupuncture in IVF: pointing in the right direction. Reprod. Biomed.Online. 2010; 21(3): 278-9.
8. Craig LB. Acupuncture performed before and after embryo transfer: a randomized controlled trial. J, Reprod. Med. 2014; 59(5-6): 313-20. 
9.  El-Toukhy. A systematic review and meta-analysis of acupuncture in in vitro fertilisation. BJOG. 2008; 115(10): 1203-13.
10. Ried K. Chinese herbal medicine for female infertility: An updated meta-analysis. Complement Ther Med. 2015; 23(1): 116-28.
11. Shen C. The Role of Acupuncture in in vitro Fertilization: A Systematic Review and Meta-Analysis. Gynecol Obster Invest. 2015; 79 (1): 1-12.
12.  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.