A new study examining whether acupuncture for IVF improves live birth rates suggests it may not help – but is that the full story?
Recent media reports like this one and also this one, of a recently published study [note] Smith C, de Lacey, S, Chapman, M, Ratcliffe, J, Norman, R, Johnson, N, Boothroyd, C, Fahey, P. Effect of Acupuncture vx Sham Acupuncture on Live Births Among Women Undergoing In Vitro Fertilization. A Randomised Clinical Trial. JAMA. 2018; 319(19): 1990-1998. doi:10.1001/jama.2018.5336 [/note] around the use of acupuncture for IVF, paint a grim story for women considering this therapeutic intervention.
But, while it is tempting to focus on the news headlines, with scientific studies – and how they are reported – the devil is always in the detail (and often, a different picture emerges).
Before we get to a summary of the study, let’s understand why acupuncture for IVF support has become a popular option for women undertaking IVF.
How and why did IVF acupuncture become so popular?
Back in the mid 2000s, there was a flurry of media interest about women who appeared to have better IVF outcomes when they used acupuncture as a supportive therapy on the day their embryo transfer.
Although these studies were small [note] Dieterle S, Ying G, Hatzmann W, Neuer A. Effect of acupuncture on the outcome of in vitro fertilization and intracytoplasmic sperm injection: a randomized, prospective, controlled clinical study. Fertil Steril. 2006 May;85(5):1347-51. Epub 2006 Apr 17. DOI:10.1016/j.fertnstert.2005.09.062 [/note] [note] Paulus WE, Zhang M, Strehler E, El-Danasouri I, Sterzik K. Influence of acupuncture on the pregnancy rate in patients who undergo assisted reproduction therapy. Fertil Steril. 2002 Apr;77(4):721-4. PMID:11937123 [/note] [note] Smith C, Coyle M, Norman RJ. Influence of acupuncture stimulation on pregnancy rates for women undergoing embryo transfer. Fertil Steril. 2006 May;85(5):1352-8. Epub 2006 Apr 5. DOI:10.1016/j.fertnstert.2005.12.015 [/note] [note] Westergaard LG1, Mao Q, Krogslund M, Sandrini S, Lenz S, Grinsted J. Acupunture on the day of embryo transfer significantly improves the reproductive outcome in infertile women: a prospective, randomized trial. Fertil Steril. 2006 May;85(5):1341-6. Epub 2006 Apr 5. DOI:10.1016/j.fertnstert.2005.08.070 [/note], and therefore the findings had limited applicability, they were also published in medical journals and regarded as demonstrating ‘promising’ improvement for women undergoing IVF.
As a result of positive media exposure, some interest from some in the medical community and word-of-mouth referrals from women who had improved IVF outcomes after using acupuncture, acupuncture has become a popular choice for women undergoing IVF.
What were the outcomes of this new study?
The overall conclusion from the authors [note] Smith, et al, 2018 [/note] is that “among women undergoing IVF, administration of acupuncture vs sham acupuncture at the time of ovarian stimulation and embryo transfer resulted in no significant difference in live birth rates. These findings do not support the use of acupuncture to improve the rate of live births amongst women undergoing IVF”.
What concerns are there with the study?
In no way does this author bring into question the professionalism and integrity of the researchers and totally accepts the integrity of the study.
However there are four basic concerns related to the structure of the study and these are worth bearing in mind as one reads the study and considers its rather stark conclusion:
- the study compared two groups of women. All women in the study had IVF and all women had three acupuncture sessions. One of these was administered on or around day 5 of the stimulation cycle. The remaining two sessions were administered before and after IVF embryo transfer. The women were split into two groups: one group received ‘real’ acupuncture into ‘real’ acupuncture points and the other group received ‘sham’ (or fake) acupuncture into fake acupuncture points. This is a bit of a pointless process. A more valuable measure would have been to compare an acupuncture + IVF group to an IVF only group, rather than just looking at two acupuncture groups. It should also be noted that only 25% of participants received only one acupuncture treatments (65.5% all three and 3.9% only two), thereby limiting the potential of the studied protocol.
- when women were being randomly assigned to the two groups, no consideration was given to the type of IVF protocol they were receiving. Consequently, more women who had blastocyst embryos were assigned to the ‘sham’ acupuncture group than women with morulla embryos. There is some evidence blastocyst embryo transfers produce better overall outcomes in IVF. Similarly, women were not randomised according to the type of IVF protocol (agonist vs antagonist) nor the method of fertilisation (routine IVF vs ICSI). All of these unaccounted for factors, might potentially affect IVF outcomes and skew the results of the study.
- the length of the intervention was very short – three treatments over a one week period and doesn’t address the important issue of ‘dose’ (that is, what is a necessary amount of acupuncture to achieve statistically significant results). The approach in this study does not reflect common clinical practice but does somewhat mirror those studies mentioned earlier, from the early 2000s.
- the conclusion, rather sloppily, says that the “findings do not support the use of acupuncture to improve the rate of live births amongst women undergoing IVF”. It does no such thing: the study shows that the acupuncture protocol it tested does not improve the rate of live births. This is a very important distinction. It’s like doing a trial on a new antibiotic and finding it doesn’t work for infection and then saying that all antibiotics don’t work. It’s a false conclusion.
How does Peter Kington acupuncturist‘s approach to IVF support differ from what was in the study?
Peter’s approach to acupuncture for IVF involves a recognition that acupuncture is an incremental therapy.
Each time acupuncture is administered, a building block is laid and the end goal is to offer a supportive therapy for women undergoing IVF.
Features of this approach include:
- recognition that fertility support with acupuncture is an incremental process and one or a few acupuncture sessions does not constitute a ‘quick fix’
- careful analysis of signs and symptoms associated with your medical diagnosis of infertility
- the creation of an individualised Chinese medicine diagnosis. To learn more about the Chinese medicine diagnosis as it relates to acupuncture for IVF head over here.
- development of a treatment plan – adopting a multi-system approach that might include acupuncture, Chinese herbal medicine, diet and lifestyle modification – that seeks to address your individualised Chinese medicine diagnosis
- selection of acupuncture points which are not standardised in the way a trial like this one seeks to standardise such things – acupuncture points are chosen based on your unique Chinese medicine diagnosis
There was an interesting study published in 2015 [note] Hullender Rubin, LE, Opsahl, M, Wiemer, K, Mist, S, Caughey, A. Impact of whole systems traditional Chinese medicine on in vitro fertilization outcomes. Reproductive BioMedicine Online (2015). http://dx.doi.org/10.1016/j.rbmo.2015.02.005 [/note] which supports this approach.
Not a randomised controlled trial (RCT), the most valued of studies, but a retrospective cohort study. What this means is the study’s authors accessed the health records of 1509 women who had previously had IVF and analysed their outcomes after the event (not during).
They divided these women into three groups:
- standard care – only IVF
- IVF + day of embryo transfer acupuncture (two treatments in one day)
- IVF + Whole System Traditional Chinese Medicine (WS-TCM)
This last group included women who had:
- ongoing acupuncture, not just at the time of cycle stimulation and embryo trasfer
- possibly took Chinese herbal medicine and other nutritional supplements
- were offered lifestyle and dietary advice to support a Chinese medicine diagnosis
- received individualised care and not standardised care
Women in this group had similar care to that offered and recommended by Peter Kington in his Brisbane acupuncture clinic.
The results of this study produced significantly different outcomes:
- 42.2% of women who had standard care – only IVF – had a ‘live birth’
- 50.8% of women who had IVF + day of embryo transfer acupuncture had a ‘live birth’
- 61% of women who had IVF + WS-TCM had a ‘live birth’ and in addition, fewer miscarriages after IVF
The upshot of this study is: women who had acupuncture had more live births. Women who had acupuncture, Chinese medicine, diet and lifestyle advice had more live births than women who just had day of transfer acupuncture.
Should I still consider acupuncture as part of my fertility plan?
The purpose of this blog post has been to discuss recent evidence around the use of acupuncture for IVF. Nothing replaces a one-on-one consult to assess your individual circumstances.
To find out more about Brisbane acupuncture practitioner Peter Kington and his approach to acupuncture for IVF, visit his IVF acupuncture page.
A word about evidence and IVF supportive therapy with acupuncture.
It is important to note that the studies mentioned in this blog post carry differing validity weights. The Smith study (2018) carries higher validity than the studies mentioned from the early to mid 2000s. It also carries higher validity than the 2015 Hullender Rubin study, only because it was retrospective and less controlled.
The evidence around acupuncture for IVF remains mixed. To understand more about an evidence based approach for acupuncture this page may be useful.