Editor's Note: Part 1 of this article appeared in the April issue.
In part 1 of this article series, I discussed in-vitro fertilization (IVF), why it is so taxing on patients, and presented some research outcomes with adjuvant acupuncture. In this second part, let's dive into the limitations of the research, how acupuncture we can help patients, as well as where we should go from here.
Is There a "There There"? Acupuncture's Potential
There are some limitations with the research investigating acupuncture and IVF. Randomized, controlled trials (RCTs) have not kept up with the way reproductive medicine is provided in the real world. This is true of both biomedical and Eastern medicine.
We also know that the research primarily looked at cycles in which an embryo transfer was with fresh, cleavage-stage embryos (three-day-old embryos) that were genetically untested.
In current IVF practice, it is less likely that patients will do ovarian stimulation and transfer in the same cycle. Instead, they will transfer a frozen blastocyst embryo (five- or six-day-old embryo thawed immediately before transfer) that is genetically normal. Genetic testing is not ubiquitous, but it is common.
Furthermore, acupuncturists would not generally provide only two acupuncture sessions and call it good. I often wonder if we expect too much from such a small dose of acupuncture.
Conventional medicine would not expect one 50 mg pill of clomiphene citrate, an ovulation induction drug, to be sufficient to induce ovulation. One would need the adequate dose of at least one 50 mg pill taken over five days starting on day three or five of the menstrual cycle for it to be even 20% effective.
Acupuncturists provide treatments over more sessions for an extended period to support patients through the ovarian stimulation and egg retrieval cycles, as well as the frozen embryo transfer cycles. A typical intervention could be weekly sessions over several months.
The other big issue is IVF acupuncture research trial design. We do not yet have the best control arm for acupuncture trials, which confounds interpretation of the results.
When a study says, "We reject acupuncture because it was no better than placebo," remember that the sham or placebo needles used in trials are not physiologically inert. Further complicating matters, they may be more potent than other placebos. We still don't have anything that looks, acts and feels like acupuncture, and is inert.
It is possible that the current research erroneously suggests we reject acupuncture as a therapy to support IVF patients because we don't have a good control arm. I do think, however, we have reasonable evidence to suggest we may positively impact IVF. In essence, there likely is a there there.*
Exploring Real-World Practice Outcomes
Patients may benefit from the holistic approach of EAM. In my research, we found acupuncture and EAM were associated with significantly more IVF live births (nearly twofold increase) and approximately 75% fewer biochemical pregnancies (a nonviable pregnancy after a positive pregnancy test) than IVF alone.1
Patients who chose EAM in this retrospective cohort study received approximately 11 individualized acupuncture sessions plus a standardized day-of-embryo-transfer acupuncture, diet and lifestyle modifications, moxibustion, and herbs when appropriate.
Others have found similar outcomes. A Colorado study found nine sessions of standardized electroacupuncture before egg retrieval plus a day of manual ET acupuncture was associated with significantly more live births and fewer miscarriages.2 And in a study of patients undergoing FET, a group from Illinois found individualized acupuncture on the day of ET was associated with more live births.3
Future Directions
When working with fertility patients, try to see them as early as possible in the IVF process. If you don't know what you are doing, that's OK. There are many online training programs you can take to familiarize yourself with reproductive medicine.
Ideally, we want to start three months before they begin a cycle. That may not be feasible, so start as soon as they show up at clinic.
Second, support the shen. As noted in part 1, this process can be emotionally brutal. Supporting the shen may mean calming the spirit, nourishing the heart, warming the kidneys, nourishing the liver and moving qi, clearing heat or draining fire, or others. It could be a combination of these approaches.
Use the tools in your toolbox to support them, and refer to a mental health provider if needed. Our goal is not just to help patients get pregnant, but also to help our patients have a healthy baby and ensurethey, too, are healthy after the birth.
Third, support the whole person with the whole system of EAM. Acupuncture is powerful, but only one modality within the system. You may also consider gua sha, moxibustion, cupping and electroacupuncture; dietary, lifestyle, exercise, and sleep modifications; qi gong and tai chi; and if appropriate, Chinese herbal medicine as well. Cupping might not be the first therapy you think of for fertility, but it can be an essential part of the whole intervention.
Take-Home Points
Acupuncture and EAM may benefit IVF patients, as two to three acupuncture sessions may help reduce IVF-related anxiety and improve birth outcomes. However, RCTs are compounded by methodological issues, limiting our ability to claim we improve one's IVF chances definitively.
Observational research of real-world acupuncture and EAM interventions suggests a significant benefit, but we need more high-quality RCTs to determine the ideal treatment dose to improve ovarian stimulation outcomes, FET birth outcomes, and psychosocial outcomes like stress, anxiety and depression.
As time goes on, I hope that the RCTs investigating an acupuncture intervention for IVF will include more sessions with the treatment tailored to the patient. I also hope we can look at birth outcomes and psychosocial outcomes like stress, anxiety and depression.
In the meantime, we can continue to support patients with high-quality and safe interventions, and share what we see in clinic.
Editor's Note: The modern implication of the phrase "there there" is that something of interest or importance exists; in this case, the possibility that acupuncture can positively impact IVF.
References
- Hullender Rubin LE, Opsahl MS, Wiemer KE, et al. Impact of whole systems traditional Chinese medicine on in vitro fertilization outcomes. Repro Biomed Online, 2015;30(6):602-612.
- Magarelli PC, Cridennda DK, Cohen M. Changes in serum cortisol and prolactin associated with acupuncture during controlled ovarian hyperstimulation in women undergoing in vitro fertilization-embryo transfer treatment. Fertil Steril, 2009;92(6):1870-1879.
- Grimm L, Phillippi K, Kamel L, Jeelani R. Getting straight to the point: does individualized pre- and post-embryo transfer acupuncture increase pregnancy rates? Fertil Steril, 2020;114(3):e450.
Dr. Lee Hullender Rubin is an internationally recognized, award-winning doctor of acupuncture, clinical researcher, and a leader in the field of integrative reproductive medicine. She practices in Portland, Ore., and provides continuing education at Rosefinch Academy.