This article is a response to recently published research (Journal of American Medical Association 2018) on outcomes for IVF patients having acupuncture.
One of our practitioners (Amy Forth) discusses this study done by personnel working at Western Sydney University and various IVF clinics in Australia and New Zealand into the effectiveness of acupuncture in relation to IVF success.
The trial, which recruited 800 IVF patients in many different IVF clinics, created an international media response; most articles had titles like this one (from The Conversation). “Acupuncture during IVF doesn’t increase chances of having a baby” which is quite misleading.
We would like to point out that the results of this study do not reflect clinical results, and contradict some of the other IVF and acupuncture studies published in recent years.
What this recent study shows us, importantly, is that DOSE matters!
What did the study in JAMA measure?
In a nutshell, the study measured the effectiveness of three acupuncture treatments over two days. One treatment was given a few days before embryo transfer (ET) and two more on the same day as ET. Effectiveness was measured by live birth rates for the group given acupuncture in comparison to a group that was given sham acupuncture (whereby a sham acupuncture needle appears to be inserted but in fact only pricks the skin).
The Acupuncture and IVF journey
ET acupuncture treatments became very popular from 2003 onwards, after the Paulus Study 2002 showed promising results in the use of acupuncture to increase pregnancy rates. In that study, clinical pregnancy rates were 42.5% in the acupuncture group, whereas pregnancy rate was only 26.3% in the control group.
The Paulus finding, and others that followed, were a catalyst for clinics like the Acupuncture Pregnancy Clinic (originally the Acupuncture IVF Support clinic) to offer support to IVF patients, however acupuncture on the day of embryo transfer was never all that was recommended. Our clinics and others like us, of course did, and still do, offer acupuncture on the day of embryo transfer and use treatment protocols based on the original research. However, the clinics also followed other IVF and acupuncture studies in which it had became clear that what Traditional Chinese Medicine had to offer IVF patients was so much more than ET acupuncture. As new research continued to emerge, The Acupuncture Pregnancy Clinic treatments and recommendations evolved, alongside the wealth of experience we had in traditional approaches to gynecology and fertility, learned from specialists in hospitals in China. The benefit of a higher dose of acupuncture quickly became apparent to practitioners and their patients, as the clinic began to recommend that patients focus on treatment before and during the stimulating phase of the IVF cycle.
Is acupuncture a magic bullet?
As this recent JAMA study found…well No.
Acupuncture, quite like IVF, is far from a magic bullet. It is however a therapy that influences physiology over time. Usually a course of treatment is required for noticeable effect.
For example, acupuncture has been shown to activate the pituitary hormones that increase ovulation, and improve menstrual regularity and overall fertility. In addition acupuncture has been well documented to reduce stress by its ability to raise endogenous opioid levels.
In fact, based on more current research, we could say the Paulus 2002 study was unusual in that it showed an effect of just two acupuncture treatments, when most acupuncture research, outside of the IVF field, would typically examine the effect of a course of acupuncture treatment that ranges between approximately 8-16 treatments. This is because the dose of the acupuncture matters.
Clinical Practice suggests that the dose of acupuncture matters.
What we see clinically, is that to help our patients and really bring about change – dose really matters. And of course, it does. Would you take three pills out of a course of medication that usually requires twelve pills and expect it to have significant and lasting effects? Acupuncture is no different. It’s NOT a magic bullet but a therapy that needs to be administered in the correct dose for the presenting condition and is unlikely to be effective if it is not. This is supported by a lot of acupuncture research in diverse areas.
So how do we know what the correct dose is?
Stener-Victorin, 1996 also made a similar observation, a full course of acupuncture treatment was needed for a good effect. They found that acupuncture improved ovarian blood flow after eight treatments and this result was maintained at follow up four weeks later. Similarly, research on hormone levels such as that by Jedel et al, 2011 showed that low frequency EA (electro-acupuncture) decreased testosterone and regulated menstrual cycles in PCOS patients after 16 weeks of treatment. Johansson et al, 2013 found that acupuncture increased ovulation frequency in PCOS patients with 10-14 weeks of treatment 2x/week. An examination of cumulative dose in acupuncture treatment of period pain, published in 2016 in the BMJ found providing 3 or fewer treatments did not appear to reduce pain compared to those who had >3 treatments for immediate, short-term or long-term outcomes. This study concluded needle location, number of points used and frequency of treatment show clear dose-response relationships with menstrual pain outcomes. While this finding did not relate to fertility directly, it highlights the impact of acupuncture dose and the relationship that dose has to therapeutic outcomes.
Conversely several studies found ET acupuncture alone had no statistical advantage Shen C et al, 2015 and Manheimer E et al, 2013 on its own, however Shen C et al, 2015 noted acupuncture administered during the IVF cycle stimulation phase and/or during implantation phase in addition to treatment at the time of transfer showed significant improvement in pregnancy rates. The finding of improved pregnancy rates when acupuncture was administered before and or during the IVF stimulation phase was repeated in a systematic review and meta-analysis by Qian Y et al, 2016, Zheng CH et al, 2012 and Zhang et al 2018.
The most recent review in 2018 found statistically significant differences were observed in rates of clinical pregnancy and live birth between the acupuncture and the control groups when acupuncture was administered through out the cycle, although more trials of consistent quality are needed.
The Hullander research is particularly relevant to what happens in our clinics.
Hullander’s research showed that acupuncture administered to IVF patients at a dose of 9-12 treatments prior to embryo transfer is associated with more live births. Lee Hullender Rubin and her colleagues analysed the outcomes of more than a thousand IVF cycles and found that women who used Chinese Medicine (acupuncture with or without herbs, dietary advice etc.), had a higher live birth rate than those doing IVF alone. The proportion of live births was 61.3% in the Chinese Medicine group and 48.2% in the usual IVF care group and 50.8% in the group having acupuncture only on day of embryo transfer. Such a whole systems approach is the approach we take at the Acupuncture Pregnancy clinics.
What about this recent study?
As participants in the JAMA study were only given three acupuncture treatments, it falls short of the dose needed to have a significant therapeutic effect. While some early ET and acupuncture research (10 years or more ago) did find an effect with 2-3 treatments, this latest study which was much larger, concluded that the effect was not significant and perhaps put to bed the idea that this small dose does have a significant effect on IVF live birth rates.
It is important we don’t accept at face value the media headlines announcing that acupuncture for IVF and fertility does not have a significant effect. The true conclusion of this study is that just three treatments may not significantly increase IVF success to such an extent that it increases live birth rate.
Where do we go from here?
It is time to re-examine what acupuncture dose means and how it works (or doesn’t work). Although some of acupuncture’s effects are quick (eg an acute sprained ankle), more commonly they are cumulative in order to make significant and lasting changes.
In summary – acupuncture is a therapy that works via administering a therapeutic dose. As the JAMA study highlights, acupuncture is not a magic bullet. It is however a very valuable therapy that has an effect when administered in the correct way and in the correct dose.