Acupuncture

The medical literature is confusing when it comes to drawing conclusions about whether acupuncture helps women deliver a healthy baby. This is due to issues associated with the research methodology that doesn’t accurately reflect what happens in real world clinical practice. Key issues associated with the research that have made it less reflective of clinical practice include low dosages of acupuncture, treatments that were not tailored to individual patients, ill-advised choice of acupuncture points, and using sham or placebo acupuncture as a control. This control has been shown to be therapeutically beneficial due to all the non-needle benefits of getting acupuncture, and therefore is not reflective of a true no treatment control. These issues are discussed in more detail below. What the research does effectively demonstrate is that acupuncture is:

• Effective at mitigating patient anxiety during treatment

• Effective compared to “no acupuncture” (usual care)

• “Dose dependent” and more likely to be effective the more often it’s administered

• More useful when started months before stimulation begins and continued through to embryo transfer

One large analysis of 800+ studies by Wang et al. showed that only ten met the criteria to even be evaluated. It was noted that among those ten, there existed “substantial variations in the results". Before we dive into whether acupuncture improves a woman's chances to have a baby, we should get familiar with the reasons acupuncture is hard to study according to western best practices. We’ll refer back to this when we consider what each study tells us or doesn’t tell us. Here are the issues in order of importance.

Confusion Around Control Arm (Most Important):

In assessing whether acupuncture “works,” we need to compare it to an alternative. Compared to doing no acupuncture (“usual care”), acupuncture generally rates favorably. But compared to something patients perceive to be acupuncture (but is not), known as a “sham” or “placebo” acupuncture, acupuncture often looks ineffective because placebo acupuncture imparts therapeutic benefit. In trials investigating other conditions like back pain placebo acupuncture is equally as effective as real acupuncture, and both are better than no treatment (usual care). This issue has caused a lot of debate in acupuncture research and most recent trials do not use placebo acupuncture as a viable comparator arm.

Inconsistent Timing & Volume of Treatment:

During an IVF cycle, treatment can be performed at many phases (e.g. leading up to a transfer, around the time of transfer, in the weeks after) and lining up the clinical data based on when treatment occurred is both important and hard. Most studies involve a total of 2 treatments performed on the day of embryo transfer, which is less treatment than many experts consider necessary.

Not "Real-World" Treatment:

Acupuncturists typically have a lot of leeway in where they place their needles. In the majority of these studies, the acupuncture treatment points were placed as per the specific protocol the investigators chose. Fixed protocols do not take into account the unique needs of an individual patient and thus do not reflect the full impact of a tailored approach patients would receive outside of a study.

Old Data:

The available data is old and comes from an era when IVF success rates were lower. That matters because when acupuncture shows a benefit, it’s often in studies where IVF patients not given acupuncture had poor results. Today, many of those same patients might have fared better making it harder for acupuncture to show additional benefit.

Inferior Endpoints:

We believe patients should be focused on whether doing acupuncture helps them have a live birth. Unfortunately, many acupuncture studies only look at whether acupuncture improves “pregnancy rates” (or some version thereof), which is useful but falls short of what we all truly care about: taking home a baby.

While the impact of acupuncture has been widely studied (over 40 studies and 10 meta-analysis) we do not believe it’s been well-studied (for the reasons mentioned above). With the data we currently have, this is how we’d summarize the findings:

• Acupuncture clearly lowers patient anxiety and duress during fertility treatment

• Greater volumes of treatment are more like to improve outcomes rather than treatment just around embryo transfer

• Acupuncture is more likely to show benefit versus “no acupuncture” but not versus a “sham” or “placebo” approach

Undergoing acupuncture during fertility treatment clearly mitigates stress. This is true regardless of whether acupuncture was administered just around the time of embryo transfer or during a longer duration of time. Below we list the better run studies on the subject and most come to a similar conclusion.

Anxiety and stress and can be excruciating and addressing this alone may make acupuncture “effective.” Psychological anxiety also impedes a patient’s ability to get more treatment.

This can limit a patient's likelihood of eventually deliverying, especially if she discontinues treatment at an early age or in the first few cycles.

One single-center study measured the impact of doing acupuncture solely around the time of embryo transfer and compared that with results from patients who underwent 12 or more treatments (in additional to herbal therapy). Investigators noted significantly higher live birth rates associated with greater treatment. While this study has challenges (single center, not prospectively randomized) we think its endpoint (live birth), sample size (500+ patients) and level of statistical significance (P < .03) make it noteworthy. A broader meta-analysis showed patients who undergo as few as 3 treatments see a statistically-significant impact in live birth rates.