Acupuncture in Treating Infertility - Research Paper Example

?Acupuncture in Treating Infertility Purpose In vitro-fertilization (IVF) treatments cost thousands of dollars, and even then, their rate of success may be low. Several IVF treatments may be needed in order to ensure a successful pregnancy. For which reason, various methods have been suggested in order to assist in making these treatments successful. One of these methods is acupuncture. Limited studies however have been carried out on this subject matter. This paper shall therefore review literature on acupuncture and whether it is effective in assisting facilitate pregnancy for women undergoing in vitro-fertilization. This paper will also consider whether it is favorable to suggest acupuncture before IVF, especially among patients with a history of polycystic ovary syndrome (PCOS) in order to reduce cost of treatments and their anxiety. Methods This literature search started with the following search words: acupuncture IVF; acupuncture IVF treatments; acupuncture impact IVF treatments; acupuncture polycystic ovary syndrome. These search words were entered in the Google Scholar search engine and the following databases: PubMed, Cochrane, EMBASE, CINAHL, and Medline Plus. Studies which complied with the following inclusion criteria were included: English language studies, published in peer-reviewed journals, published within the last 10 years (2002-2012), studies evaluating the impact of acupuncture on the success of IVF procedures, and studies assessing the impact of acupuncture during embryo transfer. Studies which complied with the above criteria were set aside for further review. Those finally chosen for this review were those which were able to utilize reliable and valid methods of research, and those which met the specific requirements of the topic being evaluated. Results Various studies were able to comply with the criteria laid out for this subject matter. These studies indicate varying results on the subject matter. In the study by Dieterle, et.al., (2006), the authors set out to establish the impact of luteal-phase acupuncture on the outcome of IVF treatments. Their study was carried out as a randomized, prospective, controlled clinical study in a University IVF center. There were about 255 infertile patients who underwent the treatment. Some of these patients were diagnosed with PCOS There were two treatment groups for this study with the first group receiving luteal-phase acupuncture and the second group receiving placebo acupuncture. The main outcome measure was the pregnancy or ongoing pregnancy of respondents. The study revealed that in the first group, the clinical pregnancy rate and the ongoing rate was significantly higher than in the second group. The authors concluded that luteal-phase acupuncture had a favorable effect on the outcome of IVF treatments among infertile patients. The methodology for this study was appropriate because it allowed for a clinical assessment and comparison of the outcomes in relation to the application of acupuncture. This study however covered a limited population and only one location; in effect, the results cannot be generalized to a larger population. The authors were also not able to establish the specific impact of acupuncture on patients with PCOS. The authors took precautions in their applications, mostly as human subjects were used with potentially beneficial effects for the intervention group and negative outcomes for the control group. The informed consent of the participants was secured thereby lending validity and reliability to the results. In the study by So, et.al. (2009), the authors discussed that acupuncture has been used during IVF treatments as a means of improving outcomes, however, there are some questions in the effectiveness of its application. The authors therefore carried out their randomized double blind study in order to compare the impact of real acupuncture with placebo acupuncture among patients going through IVF treatments. This study covered a bigger population than the Dieterle study with 370 patients randomly assigned to undergo either real or placebo acupuncture. The respondents received 25 minutes of real or placebo acupuncture before and after the treatment and the researchers evaluated the patients’ endometrial and subendometrial vascularity, serum cortisol concentration, as well as anxiety levels before and after the real and placebo acupunctures. The study indicated that the pregnancy rate was significantly higher in the placebo acupuncture group than in the real acupuncture group. There were no significant differences in the rates of ongoing pregnancy in both groups; moreover, lower endometrial and subendometrial vascularity, serum cortisol concentration, and anxiety levels were apparent in both groups. This study was able to produce results which were different from the Dieterle study as higher pregnancy outcomes were seen in the placebo group than in the real acupuncture groups. The methodology applied for this study is very much appropriate as it uses a clinical approach in the evaluation of the treatment. Clinical approaches help provide actual assessments for interventions under experimental conditions, thereby helping establish accurate and valid results. The methods applied are well explained, also allowing replication of the study. The informed consent of the respondents was also secured, ensuring a higher degree of reliability in the results. The authors pointed out that the positive effect of the acupuncture during the IVF treatment may be attributed to the change in the uterine blood flow and relaxation of stress. Oxygen flow seems to be important in achieving favorable outcomes, with hypoxia having an impact on implantation. Despite the larger population (as compared to the Dieterle study) by this study, the numbers are still limited, especially as they only covered respondents from the Centre of Assisted Reproduction and Embryology, University of Hong Kong-Queen Mary Hospital. The results of this study cannot therefore be generalized to a larger population in Hong Kong and outside Hong Kong. Nevertheless, efforts to ensure generalizability was secured by the researchers when they applied randomized methods in designating the respondents to each treatment group. In a systematic review by Chang, Chung, and Rosenwaks (2002), the authors set out to assess existing scientific rationale and clinical information on the use of acupuncture in the treatment of female infertility. The review searched the online MEDLINE database to identify relevant studies. The review revealed that even as the conceptualization of acupuncture is founded on ancient traditional medicine, studies indicate that some of the effects of acupuncture are based on endogenous opioid peptides in the central nervous system, specifically the B-endorphin. As these neuropeptides impact on the release of gonadotropin through the action of GnRH, it can be hypothesized that acupuncture can affect the menstrual cycle through such neuropeptides. There are no studies which were able to use an adequate design or sample size; moreover, there was only one prospective randomized controlled trial which evaluated the impact of acupuncture among patients going through IVF. The review established that there is no definite established role of acupuncture in the management of female infertility. The possible impact of acupuncture on the hypothalamic-ovarian axis has to be specifically examined. Moreover, there is a need to carry out more prospective randomized controlled trials on the subject matter in order to establish clear results. The nature of the methodology for this study does not allow for a clinical assessment of the intervention. This is a secondary study which draws conclusions and results from other studies. As such, these results do not provide sufficient detail in terms of clinical applications of the intervention and its overall impact on the success of IVFs. The results of the review are also inconclusive and point out similar issues also seen in previous studies, mostly in relation to the possible conduct of more prospective randomized controlled trials on the intervention. Similar vague results were also seen in the more recent systematic review by El-Toukhy and colleagues (2008). Their review set out to assess the studies or trials on acupuncture during IVF treatments and the outcomes of pregnancy as well as live births for various respondents. The review evaluated several relevant databases including MEDLINE, EMBASE, Cochrane Library, and SCISEARCH, mostly evaluating all randomized controlled trials which assessed the impact of acupuncture compared with no or sham treatment acupuncture among women undergoing IVF-intracytoplasmic sperm injection treatments. Their review was based on quality assessment and sensitivity analysis. There were 13 studies which passed scrutiny with about 2500 women randomized to either acupuncture or control groups. A meta-analysis of the results indicate that out of the 5 studies using acupuncture during egg collection, there was no significant difference seen in the outcomes of pregnancy. On the 8 studies of acupuncture during ET, there was also no significant difference on the pregnancy rate. Based on the general results of the study, the literature does not have sufficient proof which would indicate that acupuncture secures pregnancies via IVF. Once again, this study also recommends more randomized controlled trials be undertaken in order to establish sufficient results which can settle the issue. The structure of the systematic review is nevertheless reliable and replicable. The studies reviewed are valid and primary research which provides sufficient details for their review. Methodological limitations were also indicated by the authors and recommendations for future research on the subject matter based on improvements which can be applied on the intervention. The review also indicates that based on the cost and the invasiveness of acupuncture, women opting for IVF must also be advised on the fact that there is no sufficient evidence which would indicate that receiving acupuncture during IVF treatments would improve their chances of becoming pregnant. These same recommendations are also mentioned by the Chang systematic review, thereby indicating the importance of securing more clinical studies on the use of acupuncture as an assistive intervention for IVF treatments. In a recent systematic review by Zheng and colleagues (2012), the authors set out to assess the impact of acupuncture on the outcomes of IVF treatments. Studies covered by the review included randomized controlled trials which assessed the impact of acupuncture on IVF outcomes. The studies utilized intervention groups and control groups were either under no, sham, or placebo treatment. There were 24 studies, and about 5800 participants included in this review. The review indicated that acupuncture improves clinical pregnancy rates and live birth rates among women undergoing IVF, based on the results which are not placed under the Streitberger control. The review also emphasized that trends seem to indicate that the favorable impact of acupunctures in IVF can be seen if more appropriate control and acupuncture programs are utilized. This review was able to apply the appropriate means by which systematic reviews must be taken, thereby lending validity to its results. The processes involved in the study are sufficiently explained by the authors. Limitations for the review mostly related to the fact that there were large heterogeneities in the clinical trials, mostly on acupuncture treatment and acupoint selection. The varying acupuncture schemes may also lead to different clinical outcomes. Some of the courses of acupuncture treatments were also too short to effectively correct infertility states seen in long-term insufficiency or imbalance. Moreover, the acupuncture programs did not have syndrome differentiation and management based on individual qualities. The tools of acupuncture in these treatments have been seen to relate to hormone regulation, increased uterine blood flow and stress reduction. These elements have been assessed in this study, however, more specific points of discussion in relation to clinical outcomes have to be assessed in order to secure clearer results. In a pilot study by Balk and colleagues, the authors set out to establish the impact of acupuncture on perceived stress levels in women on the day of embryo transfers (ET) and to establish if perceived stress levels at ET are related to pregnancy rates or outcomes. This was an observational, cohort study at the University IVR center. The study covered 57 infertile women undergoing IVF or IVF/ICSI. There were various causes of infertility which were identified for these respondents, with some women suffering from PCOS and hormonal imbalance. Interventions included embryo transfer with or without the use of acupuncture. Outcomes related to stress scores or scales and pregnancy rates. The study indicated that 64% of women who underwent acupuncture during the ET were able to gain pregnancy and those who did not undergo acupuncture achieved a 42.5% pregnancy rate. The study also revealed that the use of acupuncture helped reduce stress before and after embryo transfer, thereby increasing the rate of pregnancy. In effect, lower stress levels during embryo transfer may have a significant role to play in improving pregnancy rates. This study however is not a randomized, blinded, or placebo-controlled study, and therefore it has lesser validity and generalizability. The study also does not test specific points of the acupuncture regimen and therefore does not consider other elements of the treatment which may impact on the outcomes of pregnancy. The impact of the acupuncture on specific women with identified caused of infertility were also not significantly detailed in the study. Madaschi and colleagues (2010) discuss that acupuncture has been considered as a supporting treatment in the management of infertility and that it has psychological effects in stress reduction for women undergoing fertility treatments. Their study set out to assess the hypothesis which indicates that acupuncture can increase pregnancy rates among patients undergoing intracytoplasmic sperm injection cycles. The patients were categorized based on age and randomized under control group or acupuncture group. Outcome measures were based on pregnancy, implantation, and abortion rates. The results indicated that the acupuncture treatment had no impact on the clinical outcomes; however when cycles and causes of infertility were assessed separately, a favorable impact of acupuncture on pregnancy was seen. Moreover, the trends in relation to the increase in implantation was seen when acupuncture was applied. The study concluded that acupuncture treatment had no significant impact when carried out immediately before and after embryo transfer based on general clinical outcomes. However, in terms of subgroup analysis, the embryo was not affected by ovarian and seminal elements, significant benefits on the outcomes of pregnancy were seen. In this study, respondents were assigned into acupuncture or control groups with the acupuncture group treated before and after the embryo transfer. Like most studies evaluating the impact of acupuncture in ART, patient knowledge is a significant limitation of this study; the placebo effect of the treatment on stress reduction is therefore very much possible. The analysis of the authors is also only exploratory, and there is a need to undertake a larger trial in order to secure more reliable results. In a study by Smith and colleagues (2006), the authors set out to assess the impact of acupuncture on clinical pregnancy rates for women going through embryo transfers as part of their IVF treatments. Their study was carried out as a single-blind randomized controlled trial utilizing a noninvasive sham acupuncture control and the respondents were women going through IVF. The women were randomly assigned to undergo acupuncture or noninvasive sham acupuncture with a placebo needle. All the respondents underwent three sessions, with the first session carried out 9 days after the injections, the second was before the transfer, and the third was after the embryo transfer. The primary outcome measures included pregnancy, implantation, and ongoing pregnancy. There were 228 subjects who were randomly assigned to the groups. The rate of pregnancy for the acupuncture group registered at 31%, and for the control group, it was 23%. In effect, respondents undergoing acupuncture had 1.5 higher odds of getting pregnant as compared to the control group, however the difference between the two groups did not reach statistical difference. In terms of ongoing pregnancy, the rate at 18 weeks was higher for the acupuncture group, however, there was no statistical difference between the two groups. Nevertheless, the authors concluded that in general, acupuncture was safe for women undergoing IVF and ETs as in general, favorable conditions have been seen among patients wanting to get pregnant. The results of this study are however limited in terms of the population covered, and the authors suggest that further research is needed in order to assess the efficacy of acupuncture at the time of embryo transfer. A large trial is needed in order to assess the physical changes in the uterus and the reproductive system with the application of acupuncture. Such study would help provide more accurate details on the current issue being evaluated. In a case series study by Johnson (2006), the author undertook his study over a span of three years with acupuncture offered to patients entering assisted reproduction therapy. Acupuncture sessions were administered at varying rates with intervals during the IVF cycle, as well as before and after embryo transfer. There were 22 patients who underwent about 26 IVF cycles, and out of these patients, there were 15 pregnancies which were achieved. This represented a 57.7% success rate compared with a 45.3% rate for patients who did not undergo acupuncture. Less stress and a more relaxed state was noted for patients undergoing acupuncture and the authors surmised that the more relaxed state may have played a huge role in increasing pregnancy rates for patients who underwent acupuncture. However, due to the wide variation in the base success rates between the centers, the results cannot be standardized. Difficulties in standardization would be seen because patients are not consistent in their compliance with acupuncture and in terms of embryo transfer. Moreover, some respondents sought additional symptoms like backache and headache to be managed with acupuncture. These elements did not allow for a more careful evaluation of pregnancy outcomes and their relationship to the acupuncture regimen. Conclusion Based on the studies reviewed above, acupuncture during IVF treatments can have a relaxing effect on patients. As such, this effect may account for the higher rates of pregnancy for patients undergoing IVF treatments. However, most of the studies indicate that there is no significant difference in pregnancy outcomes between those who underwent acupuncture and those who went through sham, placebo, or no acupuncture sessions. There was also no specific link established between the outcome of pregnancy for women with PCOS and acupuncture. The studies also recommended the need for future research, preferably, randomized controlled trials on a larger population of women undergoing IVF treatments. These trials would help provide accurate and valid results which can be used to support evidence-based practice. The results of this study also indicate the importance of observing ethical practices in research, especially in terms of securing the informed consent of respondents. This is an important aspect of research, especially research with human respondents as it informs the respondents of the risks involved in the research, as well as the degree of participation needed in the study. References Balk, J., Catov, J., Horn, B., Gencsi, K., & Wakim, A. (2009). The relationship between perceived stress, acupuncture, and pregnancy rates among IVF patients: a pilot study. Complement Ther Clin Pract., vol. 16, no. 3: 154–157. Chang, R. Chung, P. & Rosenwaks, Z. (2002). Role of acupuncture in the treatment of female infertility. Fertility and Sterility, vol. 78, no. 6, 1-12 Dieterle, S., Ying, G., Hatzmann, W., & Neuer, A. (2006). Effect of acupuncture on the outcome of in vitro fertilization and intracytoplasmic sperm injection: a randomized, prospective, controlled clinical study. Fertil Steril., vol. 85, no. 5: 1347-1351. El-Toukhy, T., Sunkara, S., Khairy, M., Dyer, R. & Khalaf, A. (2008). A systematic review and meta-analysis of acupuncture in in vitro fertilization. BJOG, vol. 115: 1203–1213. Johnson, D. (2006). Acupuncture prior to and at embryo transfer in an assisted conception unit--a case series. Acupunct Med., vol. 24, no. 1: 23-28. Madaschi, C. Braga, D., Figueira, R. Iaconelli, Jr., A., & Borges, E. (2010). Effect of acupuncture on assisted reproduction treatment outcomes. Acupunct Med, 1-5 Smith, C., Coyle, M., & Norman, R. J. (2006). Influence of acupuncture stimulation on pregnancy rates for women undergoing embryo transfer. Fertil Steril., vol. 85, no. 5: 1352-1358. So, E., Ng, E., Wong, Y., Lau, E. Yeung, W., & Ho, P. (2009). A randomized double blind comparison of real and placebo acupuncture in IVF treatment. Hum. Reprod., vol. 24, no. 2: 341-348. Zheng, C., Huang, G., Zhang, M., & Wang, W. (2012). Effects of acupuncture on pregnancy rates in women undergoing in vitro fertilization: a systematic review and meta-analysis. Fertil Steril, 1-13 Read More