Acupuncture for Infertility in Women
Department of Obstetrics and Gynaecology and Department of Physiology, Göteborg University , Sweden
This summary is intended to illustrate Acupuncture for Infertility in Women, as an example of a method of treatment that has become more established in Western medicine over the last decade. Discussed are the scientific documentation, the physiological basis for the use of acupuncture and evidence for the use of acupuncture in this area. There are unfortunately few well-designed papers on the effectiveness of acupuncture in the field of infertility. The underlying mechanisms of acupuncture are often described in the language of Traditional Chinese Medicine (TCM), and surprisingly few penetrating discussions have dealt with the physiological background of acupuncture.
What is it that make us think that acupuncture can have an effect on different conditions in reproductive medicine? In acupuncture both physiological and psychological mechanisms may be involved . Much simplified it could be explained as follows.
Both acupuncture and electro-acupuncture (EA) stimuli excite mechanoreceptors with low and high thresholds in muscles and other tissues. By stimulation of muscle afferents in somatic segments according to the innervation of the ovaries and the uterus, it is thought that inhibitoring systems in the spinal cord are activated, resulting in segmental inhibition of sympathetic outflow and pain pathways as predicted by the gate control theory.
At the same time, interneurons connected to higher control systems are excited. This results in the release of ß-endorphin via two different systems. One system includes the hypothalamus and neuronal network that projects to the midbrain and brainstem nuclei which in turn activate two pain-alleviating, descending neuronal pathways: the serotoninergic (5-HT) and the (NA) systems. There is also evidence that the hypothalmic ß-endorphin system has a central role in changes seen in autonomic functions after acupuncture. This is probably due to an inhibition of the vasomotor centre (VMC) resulting in a sustained decrease of general sympathetic tone.
In the other system is ß-endorphin released into the blood from hypothalamus via the anterior pituitary. This release is regulated by corticotropin-releasing factor (CRF). CRF promotes the release of ß-endorphin, adrenocorticotrophic hormone (ACTH) and melanocyte-stimulating hormone (MSH) in equimolar amounts through stimulation of the synthesis of their precrusor pro-opiomelanocortin (POMC). These hormones exert their effects in different target organs via the bloodstream. Stress increases the activity of the hypothalamo-pituitary-adrenal (HPA) axis and decreases reproductive functions.
In addition, acupuncture is probably one of the most effective non-pharmacological methods in terms of activating placebo effects. Indeed, acupuncture works by stimulating endogenous opioids and so, it appears, does the placebo effect.
The described findings with regard to the central ß-endorphinergic release and the decreased sympathetic tone support the idea that EA may be effective in reproductive medicine.
Is there evidence for the use of acupuncture for infertility in women?
Many childless couples hoping for pregnancy try acupuncture, but what evidence do we have today that tell us if acupuncture affects the pregnancy rate? There are a large number of studies when search on MEDLINE – most of them is in Chinese or Russian and have only English abstracts. Below you find a review of some relevant article in the area.
Gerhard et al. 1992: Infertility – auricular acupuncture
90 infertile women with recognised hormonal disorders; 45 women received auricular acupuncture over 12 sessions and were compared with 45 matched women, which received conventional hormonal therapy. Pregnancy rates – no difference between the groups. Additionally, side-effects were fewer and tendency to misscarry was lower in the acupuncture group.
Xiaoming et al. 1993: Undefined anovulation
Thirty-four women with undefined ovulatory dysfunction were treated on average 30 times with manual acupuncture according to TCM theory. Twelve get bipahsic basal body temperature curve BBT in more than 2 cycles and/or pregnancy. In addition, a regulatory effect on plasma concentrations of gondatropins and estogen, indicates an influence on the HPG axis.
Chen et al 1991: Anovulation – polycystic ovary syndrome (PCOS)
Eleven women with anovulation (9 with PCOS) and five healty controls were given 4-5 Hz EA for ovulation induction, 3 days per cycle in 3 cycles. Ovulation induction was shown in 6 of 13 cycles, in the anovulatory women. The plasma ß-endorphin concentrations decreased and the hand skin temperature increased significantly after EA treatment. The EA effect was attributed to an inhibition of high activity in the sympathetic nervous system.
Stener-Victorin et al 2000: EA - Anovulation – PCOS
Twenty-four women with well defined PCOS (typical ultrasonographic appearance, no more than 4 bleeding per year) were given 2 Hz EA twice a week for 2 weeks and then once a week, altogether 10–14 treatments. Interestingly, the LH/FSH ratio, the testosterone concentrations and the ß-endorphin concentrations decreased significantly following EA when all the participants were analysed together and blood samples before the EA period were compared with the samples taken 3 months after the last EA treatment.
This results is also supported by experimental data
In conclusion, it appears that acupuncture may have a beneficial effect on women with PCOS and anovulation, and might serve as a complement to first line therapy in ovulation induction supported by both clinical and experimental evidence. Acupuncture has not been shown to improve the pregnancy rate. However, there is a need for more RCTs in well-defined diagnoses.
Applications in human assisted reproduction
Successful IVF and ET requires optimal endometrial receptivity at the time for implantation. The endometrial circulation, or, blood flow impedance in the uterine arteries, measured as the pulsatility index (PI), considered valuable in assessing endometrial receptivity. A PI value above 3.0 will result in no pregnancy.
Stener-Victorin et al 1996; EA and uterine artery blood flow impedance
Ten women with a PI value above 3.0 were given 2 / 100 Hz EA twice a week for 4 weeks, altogether 8 treatments. PI measurements with transvaginal ultrasound were made before down regulation, before the first EA treatment, directly after the last (that is the eighth). The mean PI was significantly reduced, both directly after and 10-14 days after the eight (that is, the last) EA treatment.
In conclusion, we don't know if acupuncture improves the implantation rate – only that it improves the blood flow impedance. It will require large number of patients in each group to find that out.
Oocyte aspiration is done by transvaginal UL with puncturing of the vaginal wall to reach the follicles. It's the most painful component in the IVF procedure and successful outcome requires about 2 – 3 trials That EA induces adequate analgesia during a minor operation is not a new observation and can be referred to a clinical area where trials already exist.
Stener-Victorin et al. 1999: EA compared with alfentanil as anaesthesia during oocyte aspiration
The effect of EA (2 / 100 Hz) in combination with a paracervical block (PCB) as anaesthesia during oocyte aspiration was compared with the fast acting opiate (alfentanil) in combination with PCB.
In conclusion, EA in combination with PCB has in two repeated trials been shown to be as good as alfentanil and PBC for induction of sufficient intra-operative anesthesia during oocyte aspiration. The women have less postoperative pain, seems to recover faster. In addition, women in the EA group received significantly less additional alfentanil. Such a reduction is most likely preferable because alfentanil, has been found in the follicular fluid shortly after i.v. injection. Last but not least, we were not able to show that EA improves the pregnancy rate.
It must be pointed out that unless substantiated by research, the therapeutic use and acceptance of acupuncture cannot be extended in the future with confidence. In any case, the arguments against alternative treatments in the recently published Debate article of Renckens , are not relevant and have low, if any, scientific level. It is, of course, unethical to promise cure and recovery when the method used lacks evidence of an effect. On the other hand, it is also unethical to disallow a method that demonstrably works. There are few well-designed papers on the effectiveness of methods of treatment that are not generally established in Western medicine, but it can not best be summarised as 'much ado about nothing'. We need to stick to basics and to have open scientific minds .