You asked and we listened! Updates for IVF patients

If you are about to start your first (or another) IVF cycle you may be wondering if acupuncture may be of benefit to the way you manage the cycle and to your outcomes?

Perhaps you are interested to know more about the research examining IVF acupuncture or maybe you are unsure when to start acupuncture and what is the best timing for treatments throughout your IVF cycle?

Some of the most common questions we hear from IVF patients are

   “When should I start acupuncture ?”

   “Does it help?”

   “Is there any research that backs up recommendations?”

One of our practitioners (Amy) answers your questions here. Specifically she covers – the research, treatment timing, the dose (number of treatments) and the frequency of treatments both before and during your IVF cycle by drawing on research findings including a 2019 Meta-analysis and a 2015 Retrospective Cohort study.

Our research-based recommendations aim to clarify:

  1. When to start acupuncture and how many sessions may be of benefit
  2.  Considerations surrounding Embryo Transfer acupuncture and acupuncture in the wait between embryo transfer and pregnancy blood test.

When to start acupuncture and how many sessions may be of benefit?

The evidence indicates that if you are going to use acupuncture it may be advisable for to have it before and during the stimulation phase of the IVF cycle. It is useful for women to consider acupuncture treatment in the menstrual cycles before their IVF cycle, or before a frozen embryo transfer cycle during which time attention is paid to the uterine lining amongst other things.

Also……..according to the research, dose matters.

The most recent Meta-analysis showed there is a relationship between the acupuncture treatment dose and clinical pregnancies. Higher dose acupuncture before embryo transfer showed a significant benefit and increased pregnancy rate. In studies where more than three treatments were performed, the clinical pregnancy rate significantly improved (Smith 2019).

One study by Hullender in 2015 showed that acupuncture administered to IVF patients at a dose of 9-12 treatments prior to embryo transfer is associated with more live births. Hullender analysed the outcomes of more than a thousand IVF cycles and found that women who used a whole systems Chinese Medicine approach (acupuncture with or without herbs, dietary and lifestyle advice), 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 IVF usual care group and 50.8% in the group having acupuncture only on day of embryo transfer.

A whole systems approach is the approach we take at the Acupuncture Pregnancy clinics. While we recommend a dose similar to that used in Hullender’s study whenever possible, research suggests that having anything over 3 treatments significantly improves likelihood of clinical pregnancy. We are happy to work with you where you are, and with whatever is possible and/or manageable for you.

When exactly should I book in?

  • Ideally come in at least 1 month before your start your IVF cycle. There may be other issues related to sleep, stress, digestion etc that we can address as well as IVF preparation.
  • Our patients usually come for bi-weekly treatment for 4 weeks prior to IVF cycle and the (roughly) 2 weeks of the medicated part of the IVF cycle.
  • Electro-acupuncture and Low-level laser therapy (LLLT) may be used during IVF stimulation and/or prior to Frozen embryo transfer.

When should I consider Embryo transfer acupuncture?

Acupuncture on the day of embryo transfer has been found to show significant benefit for women who have increased stress levels or who have had multiple previous IVF cycles, or where there was a low baseline pregnancy rate (Smith 2019). Continuing this approach in the two-week wait is also helpful for these women to manage IVF related stress and anxiety. Embryo Transfer acupuncture is ideally done on same day (or within 24 hours) and on site or without involving long or stressful travel.

Is acupuncture safe in the weeks after Embryo Transfer and during pregnancy?

Acupuncture during the two week wait can be useful to reduce stress and anxiety. It also considered to be extremely safe in pregnancy when administered by a registered acupuncturist. Acupuncture treatments during your two week wait avoid any acupuncture points that are contraindicated in pregnancy.

Many patients like to continue acupuncture for the first 12 weeks of pregnancy. Acupuncture during pregnancy may incorporate points that are traditionally used to help manage nausea and fatigue and support early pregnancy physiology. Often patients report the experience as quite relaxing and rejuvenating.


How to book in for your acupuncture with us?

The Acupuncture Pregnancy Clinic has 5 locations all nearby to IVF clinics. For more information or research check out our website

You are welcome to book online here.

The Alexandria clinic (02 8372 3289) operates:

Tues and Thurs 4-8pm, Saturday 8-2pm
Pre and post embryo transfer appointments are available at other times outside of these hours on site at IVF A rooms.  Please call 0403 180 611 or email to book out of hours appointments.

The CBD clinic (02 9299 1311) operates;

Mon 7.40am to 2pm and Thurs 12pm to 7pm.

The Westmead clinic (02 9689 1614) operates:

Mon, Tues, Weds, Thurs midday/2pm – 7 pm.  Fri 7.00am -10am, and Sat 7.40am – 2pm.

The Melbourne clinic (03 9078 5759) operates:

Mon – Fri 8am – 6pm, Sat 9am – 3pm

The Gosford clinic (0481 202 881) operates:

Tues and Thurs 9:30am – 5pm, Sat 8am -1pm


For further reading please see an extended version of this blog with a full list of references online here

We wish you all the best of luck with your IVF cycle and hope we can help!


Acupuncture versus antidepressants in the management of postpartum depression: A systematic review

Acupuncture versus antidepressants in the management of postpartum depression: A systematic review. By: Komori, Akari, Arthur, David, Radford, Samara, Tan, Hsiewe Ying, Zheng, Li, An, Mira, Umeda, Rika, Zheng, Zhen, British Journal of Midwifery, 09694900, Oct2018, Vol. 26, Issue 10

Background: Antidepressants for postnatal depression may not be acceptable to women and so many may seek alternative therapies.

Aim: To evaluate the effectiveness and safety of acupuncture for postnatal depression compared with antidepressant treatment.

Methods: A literature search was conducted in English, Chinese, Japanese and Korean databases. Details of the trials were extracted and analysed.

Findings: Of the 1592 studies reviewed, three met the inclusion criteria for quantitative analysis. Two studies reported no significant differences between acupuncture and fluoxetine for depression, while the third reported significant improvements.

Conclusions: Acupuncture in postpartum depression was at least as effective as fluoxetine hydrochloride, supporting the notion that acupuncture may be a safe and effective option.

Keywords: Acupuncture; antidepressant; postpartum depression; systematic review

Postnatal depression is a significant global health issue and affects 26–85% of postpartum women who experience the so-called ‘baby blues’. Of these, 10–15% have been found to deteriorate to a major depressive disorder ([21]). In the UK, it is estimated that 1 in every 10 women are affected by postnatal depression ([45]), while in Australia and the USA the estimate is as high as 1 in 5 women ([ 3]; [10]). Postnatal depression often presents with a greater incidence with a comorbid anxiety or may develop into bipolar affective disorder ([44]). Postpartum psychosis is another comorbidity that may co-occur in 0.1–0.2% of all new postnatal women ([32]). Suicide occurs in some severe cases of postnatal depression and in Australia, New Zealand and the UK has been identified as the most common yet most preventable cause of maternal death ([35]; Australian Institute of Health and Welfare, 2017; [49]). In the UK, £8.1 billion is spent on perinatal mental health each year ([ 4]) and it is considered a priority for health policy ([51]).
The specific pathophysiology of postnatal depression is thought to be due to the rapid hormonal changes taking place across the perinatal period ([ 8]), with an overall prevalence of 13% within the first 12 weeks following birth ([46]). The physiological stress, combined with the multifaceted psychosocial stressors of pregnancy, place the predisposed individual, or those less resilient, at risk.
The effects of postnatal depression can be alarming. Some studies have indicated that mothers with postnatal depression may experience poor interaction and bonding with their child and that there is a risk of cognitive impairment of the child ([ 8]).
Western medical treatments include antidepressants and psychological and psychosocial interventions, including cognitive behaviour therapy and mindfulnessbased therapy. Alternative therapies are also sought that include omega-3 fatty acids, hormone therapy, electroconvulsive therapy and bright light therapy ([24]).
The effectiveness of psychological and psychosocial interventions is supported in the evidence, while there is insufficient evidence for other forms of management ([24]; [43]). Antidepressants carry known and unknown risks for breastfeeding infants and present potential negative effects on the child’s development. They are therefore not a preferable treatment option for many women ([36]; [24]; [27]; [47]).
In Korea, Japan and China, after birth, families encourage traditional approaches, such as prescribing the mother with a period of rest and intensive family support during the postpartum period ([25]). Another approach often adopted in Asian countries is traditional Chinese medicine, which consists primarily of acupuncture and/or herbal medicine. The treatment of postnatal depression is based on principles of syndrome differentiation. The two key sub-types are deficiency of qi (a circulating life force) and blood, and zang organs ([ 5]; [58]; [15]; [61]).
Within traditional Chinese medicine, there is growing interest in the use of acupuncture for depression in particular, with a growing body of evidence to support the benefits of acupuncture for depression in adults ([53]) as well as studies showing acupuncture achieving similar effects to medication in the management of depression across the perinatal period ([40]; [62]) In addition, acupuncture is safe ([64]; [41]) and may also be cost effective in comparison to conventional care or psychological interventions ([55]). This emerging evidence has boosted the popularity of acupuncture for treating depression in the US ([13]; [ 6]) and the UK, where it is particularly sought after by women ([31]).
However, despite the increasing demand for the use of acupuncture for depression there has yet to be a systematic review that specifically provides an overview of the evidence for using acupuncture in the management of postnatal depression.

This study aims to systematically review the literature to evaluate the effectiveness and safety of acupuncture for postnatal depression, when compared with standard psychopharmacologic antidepressant treatment.
Antidepressant therapy is widely used for postnatal depression and is often the first-line option for women who are experiencing moderate-to-severe depression, and who are not offered or cannot access psychological or psychosocial interventions ([43]). Determining the effectiveness of acupuncture compared to antidepressants may lead to acupuncture being used to complement, or act as an alternative to, antidepressants.


Search strategy
Guided by the Cochrane Handbook of Systematic Review of Interventions ([30]), electronic searches were conducted in a range of international databases, without language restrictions:

• UK: CINAHL, PubMed, EMBASE, Cochrane Library, Scopus, AMED

• China: China Biomedical Literature Database, VIP Database for Chinese Technical Periodicals, China National Knowledge Infrastructure, Wanfang

• Korea: Nanet, OASIS, Koreamed

• Japan: CiNii, IgakuChuo Zasshi (ICHUSHI).
All databases were searched from their inception to June 2018. A broad range of search terms were included, related to perinatal depression and to acupuncture therapies such as moxibustion. A combination of terms and synonyms were used, including acupuncture, electroacupuncture, auricular acupuncture, scalp acupuncture, laser acupuncture, moxibustion, acupressure, dry needling; prenatal depression, antenatal depression, postnatal depression, postpartum depression, puerperal depression, perinatal depression and randomised controlled clinical trial. Search terms were translated and modified accordingly to suit the Chinese, Korean and Japanese databases.
Terms relating to specific antidepressants were excluded from the database search, as there are various classes of antidepressants and those commonly used vary between countries. Basing the search on the types of oral antidepressants used in those studies may have limited the search and increased the risk of missing otherwise relevant literature.

Study selection criteria
Inclusion criteria were published randomised controlled trials in any language; diagnosis of depression according to standard diagnostic criteria such as the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) ([ 2]) or 5th Edition ([ 1]), the International Classification of Disease-10 Classification of Mental and Behavioral Disorders ([59]) and the third version of the Chinese Classifications of Mental Disorders (CCMD-3) ([11]); women in the perinatal period; studies comparing acupuncture or acupuncture-related therapies against any oral antidepressants; severity of disease measured by a standardised outcome measure of depression. Occurrence of adverse events; safety profiles; birth data such as gestation, Apgar score, infant weight, quality of life and mode of birth (vaginal or caesarean section); and participant/acupuncturist expectations were evaluated as secondary outcome measures, if such data were available. Strict selection criteria were adhered to in an attempt to minimise heterogeneity among included studies, thereby increasing the clinical applicability.

Data extraction and quality assessment
Database searches and article screening were independently conducted by three authors (AK, DA and SR) for the English databases; two authors (HYT and RU) for the Japanese databases; and one author for the Chinese (LZ) databases and Korean databases (MA), respectively.
Details of the trial design, participants, sample size, intervention, methodological quality and outcome measures were extracted into an Excel sheet by one author for each language and data was checked by at least one other author. Assessment of risk of bias and assessment of quality of reporting was conducted by two independent assessors based on the Cochrane Collaboration tool for assessing risk of bias ([29]) and the Standards for Reporting Interventions in Clinical Trials in Acupuncture (STRICTA) ([38]; [39]). There were disagreements on study selection, which were resolved through discussion with a third assessor (ZZ). There were no disagreements on data extraction and assessment of risk of bias.

Data analysis
Data from relevant outcome measures were entered and analysed using the Cochrane Review Manager 5.3. Only published data were included in the analysis. Dichotomous data were presented as risk ratio, while for studies using the same outcome measures, continuous outcomes were reported as mean difference with 95% confidence intervals. Heterogeneity was calculated using the tau-squared (t2), iota-squared (I2), chi-squared (χ2) statistical methods; heterogeneity was considered substantial when t2>0, with a combination of either an I2 value of more than 50% or a P-value with a χ2 test score of less than 0.10. A random-effects model was used if there was significant heterogeneity (I2≥ 50%), while a fixed-effects model was used when heterogeneity was less than 50% (I2≤ 50%) ([30]).


Description of studies
The electronic search revealed 1592 studies. After screening of titles and abstracts, duplicates and irrelevant hits were excluded for the reasons shown in Figure 1. Three studies met the inclusion criteria for quantitative analysis ([12]; [18]; [63]). Due to insufficient reporting of data from the Hamilton Rating Scale for Depression (HRSD), the [18] study was excluded, leaving two studies ([12]; [63]), involving a total of 112 participants included in the meta-analysis. The electronic study selection strategy is pictorially represented in the PRIMSA reporting guideline diagram ([42]) (Figure 1).
Graph: Figure 1. PRISMA Flow Diagram for Study Selection
All three studies were conducted in China and compared acupuncture with the oral antidepressant fluoxetine. All participants were women above the age of 18 years, without previous diagnosis of other psychiatric disorders such as schizophrenia or bipolar disorder, or other serious physical illness. Diagnosis of depression was based on the criteria of the CCMD-3 in postpartum women, with no mention of time of onset after birth. All three studies adopted the HRSD as the primary outcome measure; one study ([63]) evaluated quality of life using the 36-Item Short Form Health Survey (SF-36); two studies evaluated the occurrence of adverse events ([12]; [63]). Interestingly, none of the studies used the Edinburgh Postnatal Depression Scale (EPDS).

Assessment of risk of bias
The criteria for assessment of risk of bias included random sequence generation, allocation concealment, blinding and incomplete outcome data. Selective reporting could not be assessed as none of the studies had a published protocol nor had been registered before publication. Two studies ([12]; [63]) mentioned using a random table of numbers and were judged with low risk for sequence generation; none of the studies mentioned allocation concealment and were judged with unknown risk. Blinding of participant and treatment personnel was not possible due to the different forms of treatment modalities between groups; however, none of the studies mentioned whether outcome assessors were blinded and were therefore judged with high risk of detection bias. There were no drop-outs in any of the three studies; therefore, there was a low risk of attrition bias (Figure 2).
Graph: Figure 2. Risk of bias

STRICTA assessment
STRICTA is a reporting system that is designed for assisting authors to present their acupuncture trial in an accurate, transparent, and complete manner in order to facilitate clear interpretation and replicability ([39]). As presented in Tables 1 and 2, all studies clearly described the acupuncture points used; however, none offered explanations of practitioner background and some details of needling were lacking. Two studies reported that the needling sensation, de qi, was sought and all three studies clearly stated stimulation methods employed. Frequency and duration of treatment ranged from 5 times per week for 6 weeks ([12]), 5 times per week for 4 weeks ([63]), to 30 consecutive daily treatments ([18]).

Table 1. Characteristics of included studies

Sample size
Age group (years)
Diagnostic criteria; disease severity
Treatment Intervention
Control intervention
Outcome measure (s)
Style of acupuncture
Acupuncture points
Chen et al (2010)
T=24–34 (mean=27.8)C=22–33 (mean=26.7)

Baihui (GV 20);Sishencong (EX);Neiguan (PC 6);Hegu (LI 4); Taichong (LR 3);Sanyinjiao (SP 6);Zusanli (SP 36)
Even method stimulation was performed until a comfortable distension of the local region was felt. Needles were retained for 30 minutes. Treatment 5 times a week for 6 weeks
Orally administered fluoxetine hydrochloride, 20mg, once per day for 6 weeks
HRSD score and reduction in HRSD (%)

Dong and Gao (2014)
22–34 (mean=26.7)

Threading scalp acupuncture Standard acupuncture
Xuanlu (GB5) through Xuanli (GB6);Naohu (Du17) through Qiangjian (Du18);Toulinqi (GB15) through Yangbai (GB14);Shuaigu (GB8) through Qubin (GB7);Shenting (Du24) through Yintang Neiguan (PC6);Shenmen (HT7);Hegu (LI4);Zusanli (ST36);Sanyinjiao (SP6);Taichong (LR3)
For threading scalp acupuncture, each needle was stimulated for 1 minute and retained for 40 minutes. For standard acupuncture, each needle was stimulated using rotation/lifting and thrusting method after de qi was achieved, and then retained for 40 minutes. Treatment once a day for 30 days
Orally administered fluoxetine hydrochloride, 20mg, once per day for 1 month
Reduction in HRSD (%) and score (score not repor ted)

Yu et al (2015)
T=28± 16C=29 ±16
Standard acupuncture (Sun Si Miao’s 13 ghost points)
Shuigou (GV 26);Shangxing (GV 23);Fengfu (GV 16);Chengjiang (CV 24);Laogong (PC 8)

For severe cases: alternate with Daling (PC 7);Huiyin (CV 1);Shenmai (BL 62);Shaoshang (LU 11);Baihui (GV 20);Shenting (GV 24)
Even method stimulation was performed after de qi was achieved; needles retained for 30 minutes. Treatment once a day, five times a week, for 4 weeks
Orally administered fluoxetine hydrochloride capsules, 20mg, once per day for 4 weeks
HRSD score, SF-36 score

7 T: treatment size; C: control; D: drop-out; CCMD-3: Chinese Classifications of Mental Disorders; HRSD: Hamilton Rating Scale for Depression

Table 2. STRICTA checklist for included studies

Chen et al (2010)
Dong and Gao (2014)
Yu et al (2015)
1. Acupuncture rationale
1a) Style of acupuncture (e.g. traditional Chinese medicine, Japanese, Korean, Western medical, Five Element, ear acupuncture, etc)

1b) Reasoning for treatment provided (based on historical context, literature sources, and/or consensus methods) with references where appropriate

1c) Extent to which treatment was varied

2. Details of needling
2a) Number of needle insertions per subject per session (mean and range where relevant)

2b) Names (or location if no standard name) of points used (uni/bilateral)

2c) Depth of insertion, based on a specified unit of measurement, or on a particular tissue level

2d) Response sought (e.g. de qi or muscle twitch response)

2e) Needle stimulation (e.g. manual, electrical)

2f) Needle retention time

2g) Needle type (diameter, length, and manufacturer or material)


3. Treatment regimen
3a) Number of treatment sessions

3b) Frequency and duration of treatment sessions

4. Other components of treatment
4a) Details of other interventions administered to the acupuncture group (e.g. moxibustion, cupping, herbs, exercises, lifestyle advice)
4b) Setting and context of treatment, including instructions to practitioners, and information and explanations to patients
5. Practitioner background
5) Description of participating acupuncturists (qualification or professional affiliation, years in acupuncture practice, other relevant experience)
6. Control or comparator interventions
6a) Rationale for the control or comparator in the context of the research question, with sources that justify this choice
6b) Precise description of the control or comparator. If sham acupuncture or any other type of acupuncture-like control is used, provide details as for items 1 to 3 above.

Primary outcome measures

Disease severity
The HRSD was the primary outcome measure in all three studies and is one of the earliest and most widely used scales for clinical studies of depression ([16]). The total score of the 17 items, with a maximum possible of 52, indicates the presence and severity of the condition: 0-6 indicates no depression; 7-17 indicates mild depression; 18-24 indicates moderate depression; while scores above 24 indicate severe depression. A reduction of at least half the score from baseline is said to be a significant change ([16]).
One study ([18]) did not report the HRSD scores and could not be included in the meta-analysis. The authors of the study reported that acupuncture had an effective rate of 86.7% compared to the effective rate of fluoxetine of 73.3%, with no indication if there was a significant difference.
[63] found that both acupuncture and fluoxetine were effective, with the outcomes in the acupuncture group significantly higher. However, this result differs from that of [12], who also found both therapies effective, but reported no significant differences between fluoxetine and acupuncture (Table 3).

Furthermore, the meta-analysis (Table 4) comparing the combined data from both studies revealed no significant differences between the acupuncture and fluoxetine groups. A high level of heterogeneity (I2=84%; P=0.36) was apparent in the results of the meta-analysis, and may have stemmed from differences in acupuncture treatments, whereby completely different sets of acupuncture points were used in each study.

Table 3. HRSD Scores from Yu et al (2015) and Chen et al (2010)

Yu et al (2015)
Chen et al (2010)
29.83 ± 2.97
28.90 ± 3.17
20.192 ± 2.078
20.346 ± 1.979

After 2 weeks

16.885 ± 1.986
17.346 ± 1.853
After 4 weeks
11.53 ± 5.87
16.50 ± 8.22
13.615 ± 2.368
14.154 ± 2.185

After 6 weeks

10.500 ± 2.902
10.538 ± 2.716

• 8 Yu et al (2015): Experimental group received acupuncture treatment once daily for 30 consecutive days, totaling 30 sessions. Control group received oral fluoxetine hydrochloride at 20 mg per day for 30 consecutive days.
• 9 Chen et al (2010): Experimental group received acupuncture treatment once a day, 5 times per week for 4 weeks, totaling 20 sessions. Control group received oral fluoxetine capsules at 20 mg per day for 4 weeks.
• 10 HRSD: Hamilton Rating Scale for Depression

Table 4. Meta-analysis of HRSD


Mean Difference
Mean Difference
Study or subgroup
IV, Random, 95% Cl
IV, Random, 95% Cl
Chen et al (2010)
-0.04 [1.57, 1.49]

Yu et al (2015)
-4.97 [-8.58, -1.36]
Total (95% Cl)


-2.22 [-7.02, 2.58]

• 11 Heterogeneity: Tau2 = 10.16; Chi2 = 6.07, df = 1 (P=0.01); Iota2 = 84% Test for overall effect: Z = 0.91 (P=0.36)
• 12 HRSD: Hamilton Rating Scale for Depression

Secondary outcome measures

Quality of life
The SF-36 is a self-administered 36-item questionnaire that measures health based on eight dimensions: physical functioning, social functioning, role limitations, mental health, vitality, pain, general health perception and health change ([ 7]).
One study ([63]) used the SF-36 questionnaire and reported that acupuncture performed significantly better than fluoxetine in several dimensions of the SF-36, including pain, general health, vitality, social functioning, mental health and health transition (Table 5).

Table 5. SF-36 Scores from Yu et al (2015)

Experimental (acupuncture)
Control (fluoxetine)
End of Tx
End of Tx
Physical functioning
70.80 ± 22.96
89.01 ± 8.38
68.24 ± 21.77
76.49 ± 17.79
Physical role functioning
26.85 ± 37.45
82.10 ± 28.29
17.57 ± 31.11
59.46 ± 28.29
Bodily pain
55.48 ± 28.53
74.02 ± 18.74
54.27 ± 29.62
77.51 ± 23.03
General health perceptions
54.81 ± 23.88
74.85 ± 14.71
56.89 ± 19.66
57.43 ± 14.70
54.17 ± 24.53
81.02 ± 16.43
59.80 ± 27.97
56.88 ± 17.84
Social role functioning
32.92 ± 42.33
90.57 ± 25.95
39.64 ± 47.03
72.97 ± 38.36
Emotional role functioning
56.00 ± 20.73
76.90 ± 14.46
64.43 ± 23.98
70.81 ± 8.16
Mental health
2.69 ± 0.76
3.91 ± 0.68
2.36 ± 0.49
3.41 ± 0.67
Health transition
38.46 ± 28.64
55.83 ± 14.00
38.43 ± 19.12
45.57 ± 11.61

Source: Yu et al (2015); SF-36: 36-item Short Form Health Survey
Occurrence of adverse events
[63] reported that neither the acupuncture nor the fluoxetine group had any adverse events. [12] reported that there were no adverse events in the acupuncture group, but in the fluoxetine group, there were four cases of nausea, four cases of decreased appetite and two cases of dizziness.

Only three studies, all originating in China, met the inclusion criteria for this review. Despite the high risk of bias and small sample sizes, each reported that acupuncture was effective in improving postnatal depression and comparable to the oral antidepressant, fluoxetine hydrochloride. One study reported that acupuncture performed significantly better in improving certain aspects of quality of life ([63]). The meta-analysis showed no significant difference between acupuncture and fluoxetine, which supports the hypothesis that acupuncture is equally as effective as fluoxetine in the management of postnatal depression. There was a high level of heterogeneity, which calls for further research to determine the best practice related to acupuncture technique and point selection, and evidence to guide frequency and length of treatment for treating postnatal depression.
There have been a number of previous reviews on acupuncture for depression, including an updated Cochrane review ([53]) and a systematic review of systematic reviews on the topic ([22]). According to the latter study, there were mixed conclusions among the systematic reviews, with those originating in China or consisting primarily of studies from China being more likely to present positive data; two reviews showed that there were no significant differences in effectiveness between acupuncture and antidepressants ([64]; [53]). There was also a general consensus in the reviews about the lack of high quality studies, which may affect the conclusions. It should be noted that none of the studies were focused specifically on postpartum women.
Acupuncture is said to help in the management of psychological conditions such as depression by stimulating the secretion of hormones such as serotonin and encephalin in the central nervous system and plasma ([ 9]). Another study showed that acupuncture inhibited the inflammatory response by modulating nuclear factor kappa B (NF-kB) in the brain, resulting in antidepressant-like effects ([37]). However, neither of these two studies mentioned acupuncture point specificity; that is, whether the choice of acupuncture points played a role in the results.
When considering the management of postnatal depression, one of the main concerns is safety. The most recent review on this topic ([41]) considered acupuncture as an inherently safe treatment modality when administered by well-trained practitioners. They also found acupuncture a safe and well-tolerated treatment option for major depressive disorders ([41]). Other systematic reviews on the safety of acupuncture during pregnancy, have concluded that adverse events are minor or small in number when the treatment is applied appropriately ([23]; [48]; [14]). There were no adverse events relating to acupuncture reported in the reviewed studies, supporting the view that acupuncture is safe and well tolerated.
Apart from being the first systematic review on acupuncture for postnatal depression, this article focused on an important question highly relevant to clinical practice: is there a safe and effective adjuvant or alternative management to antidepressant medication for postnatal depression? The previous Cochrane review on the effects of acupuncture for depression included multiple types of controlled interventions and showed no significant difference between verum acupuncture and sham acupuncture ([53]). Indeed, the discussion regarding the therapeutic or placebo effects of acupuncture compared to sham acupuncture is ongoing ([65]) although there are studies that found different physiological responses were elicited when applying verum acupuncture compared to sham acupuncture ([20]). As the objective of this review was to evaluate the effectiveness, not the efficacy, of acupuncture, only studies specifically comparing acupuncture with the routine management of postnatal depression with oral antidepressants, were included. A comparison between acupuncture treatment and psychological or psychosocial intervention was not possible due to a lack of such studies.

Acupuncture treatment for postpartum depression
All three studies used different forms of acupuncture: standard acupuncture points ([12]), combination of standard acupuncture and threading scalp acupuncture ([18]) and acupuncture of Sun Si Miao’s 13 ghost points ([63]). The acupuncture points used in two of the studies were similar standard points, chosen to strengthen the mother after labour and to enable smooth flow of qi. The additional threading scalp acupuncture was justified as assisting with managing the hormone imbalance in the postpartum period ([18]). [63] explained that Sun Si Miao’s 13 ghost points are traditionally used for mental health conditions and the points were so named due to past beliefs that these conditions were caused by ghosts. The points are said to calm the mind and restore the balance of yin and yang to assist in postnatal depression.
Diagnosis of postnatal depression
As well as adopting a diagnosis according to the CCMD-3, the three studies used a cut-off of 17 for the HRSD, which indicates moderate-to-severe depression. However, while two of the studies mentioned the exclusion of ‘other mental or depressive disorders’ ([18]; [63]), none of the studies clearly stated whether participants suffering from depressive disorders were excluded before or during pregnancy. Furthermore, the onset of postnatal depression was not reported or mentioned in the inclusion/exclusion criteria. The DSM-IV states that the onset of postnatal depression will usually occur within 4 weeks of birth ([ 2]), although postnatal depression studies have varied between 1 week and 1 year post-birth ([34]).
Postnatal depression is likely to be a culturally sensitive topic, which may have influenced the number of studies conducted. [28] explain the prevalence of postnatal depression as it varies between different countries. Based on findings using the EPDS, a high prevalence was found in Italy, Korea and Taiwan (34–57%), while the USA and the UK was lower at 12.9–15.4%, but similar to China and Japan at 13.9–21.6%. The prevalence in Australia and New Zealand was even lower (9–10.1%), while in Singapore and Malaysia the prevalence ranged from 0.5–9%. The reason for such differences in prevalence may be due to multiple factors, including different attitudes and perception towards marriage, childbearing and depression, as well as varied availability of adequate healthcare services ([28]). Stigma towards mental illness may also be a part of this picture, with more people of Asian or non-western backgrounds tending to refer to somatic symptoms rather than emotional problems ([34]). Certain cultures may also use traditional diagnostic terms to explain the condition, such as ‘wind or heat in the head’ or ‘anger disorder’ ([33], [34]). Given that perception and expression of postnatal depression are deeply culturally embedded, the HRSD may not be valid as a measure of postnatal depression in Chinese populations. Furthermore, the ‘protective’ role of traditional practices after labour, such as receiving help from mother or mother-in-law and being confined at home for a period of time immediately after giving birth, is thought to be an influence on mood, but is as yet untested ([34]).
Implications for research
It is acknowledged that the small number of studies, small sample sizes, and presence of high risk of bias and high level of heterogeneity call for caution in interpreting these results. It is worth noting that acupuncture trials are inherently high for risk of bias due to the inability of blinding the clinician delivering the acupuncture treatment. It is also difficult to eliminate the placebo effect such as subjects’ expectation and motivation for seeking and receiving complementary and alternative medicine. Recent efforts have aimed at clarifying the effect of acupuncture by improving study designs and/or developing a variety of sham acupuncture methods, including the invention of the Streitberger needle ([56]). The evidence remains limited on the topic; however, there are studies that indicate the presence of different biological effects between verum acupuncture and placebo acupuncture ([20]).
Larger, more rigorous studies with an equally strong focus on the safety of acupuncture need to be conducted to enable firmer conclusions. The scope of postnatal depression may also be broadened to include ante- and perinatal depression, considering that around 50% of women who experience postnatal depression show symptoms in the antenatal period ([ 1]). Future studies may also consider a more pragmatic approach that allows personalised acupuncture treatment, or integrated treatment of acupuncture and modern medication, in order to better reflect clinical practice. Furthermore, perinatal healthcare should be culturally responsive. Generalisability of results between Chinese and European samples need to be better explored and cultural factors better understood and taken into consideration. On another note, the HRSD may not be the most appropriate outcome measure tool for postnatal depression as it is conventionally used for major depressive disorders. The EPDS is a widely used, valid and reliable instrument, considered appropriate for use in postnatal depression, and it is surprising that none of the studies mentioned this. Future studies should consider comparing the validity and the contrasting findings of the HRSD and the EPDS.
Implications for the UK
This review was confined to studies conducted in China where acupuncture is a well-established treatment that many people receive regularly. In contrast, in the UK, acupuncture is not yet a widely practised therapy, although it is becoming more popular (particularly among women) and its demand is increasing for many health issues including depression ([31]). Given the risk associated with pharmacological interventions, complementary and alternative therapies such as acupuncture are becoming important treatment options for perinatal depression ([17]). In the UK and Australia, more GPs are in favour of acupuncture given in primary care and, in Australia in particular, many GP referrals are made for acupuncture ([57]). In the UK, acupuncture is not commonly recommended by GPs, who play a role in postnatal care, including detection and assessment of postnatal depression ([26]). In the US, acupuncture is an increasingly accepted treatment and services are now provided in many conventional and academic medical centres ([19]; [50]; [ 6]). Given acupuncture’s inherently safe nature as well as increasing popularity and demand in the UK, GPs may provide referrals or suggest acupuncture as an option for women with perinatal mental health issues, including postnatal depression.
Strengths and limitations
A strength of this review is its broad, deep and international scope of literature search, which included not only UK and Chinese databases, but also the Korean and Japanese databases. Despite the widespread search, only three studies matched the criteria for this study. Rigorous steps were adopted for extracting the data by using the CONSORT ([52]) and the STRICTA ([38]; [39]) guidelines. The review is limited by the number of studies, small sample sizes and a presence of a high risk of bias. The variation in treatment protocols are a limitation of studies on acupuncture for depression ([60]). Another criticism is that because acupuncture follows the holistic approach of traditional Chinese medicine, treatment should therefore be personalised rather than standardised as was the case in these studies ([54]).
Postnatal depression is a significant issue, and both practitioners and patients are searching for treatment strategies with the fewest side effects to the mother and baby. This review provides preliminary yet encouraging results showing that acupuncture may be well-tolerated and has the potential to play a role in the management of postnatal depression. It also updates the evidence of acupuncture to assist patients in making an informed decision. This review may act as an initial working platform to assist in moulding future rigorous studies and building stronger evidence.
Key points

• Acupuncture is a well-tolerated treatment option with the potential for playing a role in treating postnatal depression

• A small number of studies suggest that acupuncture may be as effective as antidepressant therapy in postnatal depression. It also provides a safer option for midwives and mothers to consider in the postpartum period

• More studies need to be conducted on postnatal depression in conjunction with psychological therapies such as mindfulness and cognitive behaviour therapy (CBT)

• The studies reviewed all used the Hamilton Rating Scale for Depression (HRSD) and this needs to be compared to studies in which the Edinburgh Postnatal Depression Scale (EPDS) is used to screen for depression
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Declaration of interests: The author has no conflicts of interest to declare.
Ethical approval: Not required.
Review: This article was subject to double-blind peer review and accepted for publication on 30 July 2018.
By Akari Komori; David Arthur; Samara Radford; Hsiewe Ying Tan; Li Zheng; Mira An; Rika Umeda and Zhen Zheng


Controlling the Recurrence of Pelvic Endometriosis after A Conservative Operation: Comparison between Chinese Herbal Medicine and Western Medicine

Chin J Integr Med 2013 Nov;19(11):820-825
Controlling the Recurrence of Pelvic Endometriosis after A
Conservative Operation: Comparison between Chinese
Herbal Medicine and Western Medicine
ZHAO Rui-hua (赵瑞华)1, HAO Zeng-ping (郝增平)2, ZHANG Yi (张 毅)3, LIAN Feng-mei (连凤梅)1,
SUN Wei-wei (孙伟伟)1, LIU Yong (刘 永)1, WANG Rui (王 蕊)4, LONG Li (龙 隶)5,
CHENG Ling (程 玲)6, DING Yong-fen (丁永芬)6, SONG Dian-rong (宋殿荣)7,
MENG Qing-wei (孟庆伟)3, and WANG Ai-ming (王蔼明)8

ABSTRACT Objective: To compare the clinical effect of Chinese medicine (CM) and Western medicine (WM)
for controlling the recurrence of pelvic endometriosis after a conservative operation. Methods: The study was a
multi-center, randomized, parallel controlled and prospective clinical trial. Patients were randomly divided into two
groups: CM group (106 cases) and WM group (102 cases). Drugs were given to patients during 1–5 days of the
fi rst menstruation after a conservative operation in both groups. Patients with stages Ⅰ and Ⅱ (revised American
Fertility Society) were treated for 3 months, while the patients with stages Ⅲ and Ⅳ were treated for 6 months.
The patients in the CM group were treated using three types of Chinese herbal medicine based on syndrome
differentiation. Patients in the WM group were treated using gonadotropin releasing hormone agonist (GnRH-a)
or gestrinone. Patients treated with GnRH-a received add-back therapy of Tibolone Tablets once a day after 4
months of treatment. Any cases of dysmenorrheal chronic pelvic pain, menstruation and any adverse reactions of
patients were recorded once a month during the preoperative and postoperative periods and once every 3 months
during the follow-up period. During the preoperative, postoperative and the follow-up periods, patients underwent
type B ultrasonography of the pelvis and measurements of serum CA125 levels, gynecologic examination, routine
evaluations of blood, urine, hepatic function (glutamate pyruvate transaminase), renal function (blood urea nitrogen)
and electrocardiograms. During the follow-up period they underwent type B pelvic ultrasonography, measurement
of serum CA125 levels and further gynecologic examinations. The two treatments were compared for clinical
recurrence rates, pregnancy rates and the incidence of adverse reactions. Results: The incidence and timing of
recurrence of endometriosis were not signifi cantly different between the two groups. The fi rst pregnancy achieved
by the patient in the CM group was signifi cantly earlier than that in the WM group (P<0.05). Moreover, the incidence
of adverse reactions in the WM group was signifi cantly
higher than in the CM group (P<0.01). Conclusions:
Treatment with Chinese herbal medicines prevented
the recurrence of endometriosis after a conservative
operation, improved the conception rate and showed
fewer and lighter adverse reactions than did treatment
with WM therapy. Treatment with Chinese herbal
medicine meets the need of patients wishing to have
a child following endometriosis and is an appropriate
form of clinical treatment.

KEYWORDS endometriosis, infertility, fertilization
in vitro, embryo transfer, recurrence rate, pregnancy
©The Chinese Journal of Integrated Traditional and Western
Medicine Press and Springer-Verlag Berlin Heidelberg 2012
Supported by the Key Projects of the National Science and
Technology Pillar Program during the 11th Five-Year Plan
Period (No. 2006BA104A)
1. Department of Gynecology, Guang’anmen Hospital, China
Academy of Chinese Medical Sciences, Beijing (100053),
China; 2. Obstetrics and Gynecology Department, Beijing
Friendship Hospital, Capital Medical University, Beijing
(100050), China; 3. Department of Obstetrics and Gynecology,
Beijing Hospital, Ministry of Health, Beijing (100730), China;
4. Department of Obstetrics and Gynecology, Beijing Tiantan
Hospital Affi liated to Capital Medical University, Beijing (100050),
China; 5. Department of Gynecology, Fuxing Hospital, Capital
Medical University, Beijing (100038), China; 6. Department of
Gynecology, Wangjing Hospital of China Academy of Chinese
Medical Sciences, Beijng (100102), China; 7. Department of
Gynecology, Second Affiliated Hospital to Tianjin University
of Traditional Chinese Medicine, Tianjin (300150), China; 8.
Department of Obstetrics and Gynecology, PLA Navy General
Hospital, Beijing (100048), China
Correspondence to: Prof. ZHAO Rui-hua, Tel: 86-10-88001139,
DOI: 10.1007/s11655-012-1247-z

Endometriosis (EMs) is an estrogen-dependent
disease that is common frequently encountered
and stubborn in women of childbearing age. In
recent years, the morbidity of EMs has increased
significantly, reaching 10% to 15% in the generalChin J Integr Med 2013 Nov;19(11):820-825 • 821 •
population and exceeding 30% among patients with
chronic pelvic pain or infertility.(1) Surgery is the first
treatment for pelvic EMs, but it is difficult to control
postoperative recurrence. Some studies reported that
the recurrence rate reached 36% by 5 years after
surgery(2) and the recurrence rate after a conservative
operation with preservation of fertility can be as high
as 50%.(3) Surgery for recurrence is difficult and
causes major bleeding; moreover, recurrence of EMs
is still possible after surgery.(4) Thus, drug treatment
after the operation is the key to eliminate or suppress
any residual lesions and to prevent recurrence. The
treatment of EMs recurrence with Chinese herbal
medicine is now an active research fi eld. To compare
the clinical effec of controlling the recurrence of pelvic
EMs after a conservative operation between Chinese
medicine (CM) and Western medicine (WM), we
ran a multi-center, randomized, parallel controlled
and prospective clinical trial. We measured the
rates of recurrence and successful pregnancy and
the incidence of adverse reactions between the two
Diagnostic Criteria
Methods on the Manual on the Diagnosis and
Therapy of Endometriosis(5) and Chinese Obstetrics
and Gynecology(6) were used to establish the diagnostic
criteria. The clinical stages were graded according to
the revised scheme published by the revised American
Fertility Society (r-AFS) in 1985.(6) The criteria of
symptoms and signs for syndrome differentiation were
established based on the published references(7,8) and
the clinical experience of our group.
Inclusion Criteria
Patients were included according to the following
screening criteria: (1) meet the diagnostic criteria
and CM syndrome differentiation criteria; (2) without
a history of serious drug hypersensitivity; (3) have
never undergone an open operation or laparoscopic
operation for EMs; (4) have not taken any other drugs
to treat EMs for 6 months before the operation; (5)
have no serious primary disease in the cardiovascular,
cerebrovascular, hepatic, renal or hematopoietic
systems and lacked any history of psychiatric illness;
(6) non-lactating woman aged from 18 to 45 years.
According to the above screening criteria,
patients with clinical and pathological features of
ovarian EMs and/or deep infiltrating EMs were
assigned to treatment groups during the first to fifth
days of the first menstruation after a conservative
operation. All patients signed informed consent forms.
Exclusion Criteria
Patients with EMs combined with adenomyosis
and any patients using other drugs to treat EMs after
the operation were excluded.
A total of 208 patients with pelvic EMs after a
conservative operation were recruited from outpatient
and inpatient departments of eight centers in China
from March 2008 to May 2010. The centers were
Guang’anmen Hospital; Beijing Friendship Hospital
Affiliated to Capital Medical University; Beijing
Hospital of the Ministry of Health; Beijing Tiantan
Hospital Affi liated to Capital Medical University; Fuxing
Hospital Affiliated to Capital Medical University;
Wangjing Hospital of the China Academy of Chinese
Medical Sciences; Second Affiliated Hospital to
Tianjin University of Traditional Chinese Medicine and
the PLA Navy General Hospital. The patients were
randomly assigned to two groups by randomized
blocks method. There were 106 patients in the CM
group and 102 patients in the WM group.
Drugs began to be given to the patients during
days 1–5 of their first menstruation in both groups.
The patients with r-AFS stages Ⅰ and Ⅱ EMs were
treated for 3 months, while the patients with stages Ⅲ
and Ⅳ were treated for 6 months.
The patients in the CM group were treated using
three types of Chinese herbal medicine (Kangmei
Pharmaceutical Co., Ltd., China) treatment based
on syndrome differentiation.
The herbs were
decocted with water and given to the patients by oral
administration twice a day, with 21 days as one course.
The decoction was given again during days 1–5 of the
next menstrual period. Modified Guifu Decoction ( Radix Aconiti lateralis Preparata, 10 g; Ramulus
Cinnamomi 10 g; Radix Linderae 10 g; Rhizoma
Sparganii 10 g; Rhizoma Curcumae 10 g; Spina
Gleditsia 14 g and Radix Salviae Miltiorrhizae 25 g) was
given to patients with syndrome of cold congeal and
blood stasis to the warm meridians and dissipate cold,
activate blood and resolve stasis. Modified Danchi•
Decoction (Radix Bupleuri 10 g; Rhizoma
Cyperi 14 g; Radix Salviae Miltiorrhizae 25 g; Radix
Paeoniae rubra 15 g; Rhizoma Curcumae 10 g; Spina
Gleditsia 14 g and Rhizoma Sparganii 10 g) was
given to the patients with syndrome of qi stagnation
and blood stasis to sooth the Liver (Gan) and regulate
qi, activate blood and resolve stasis.
Modifi ed Qidan
Decoction [Astragalus membranaceus (Fisch.)
Bge. Preparata 30 g, Salvia Miltiorrhizae 25 g, Radix
Paeoniae rubra 15 g, Rhizoma Curcumae 10 g,
Poria 15 g and Rhizoma Atractylodes Macrocephala
15 g] was given to the patients with syndrome of
qi deficiency and blood stasis to invigorate Spleen
(Pi) and replenish qi, activate blood and resolve
Drugs were added or omitted in the CM group
depending on patients’ symptoms.
Thus, the patients
with dysmenorrheal were treated by adding Rhizoma
Corydalis 10 g, Radix Linderae 10 g; the patients with
anal pain upon bearing down were treated by adding
Rhizoma et Radix Notopterygii 8 g.
The patients with
lumbago were treated by adding Radix Dipsaci 30 g
and Cortex Eucommiae 10 g.

T h e p a t i e n t s i n t h e W M g r o u p r e c e i v e d
hypodermic or intramuscular injections of 3.75 mg
GnRH-a (Triptorelin Acetate for Injection, Ipsen
Pharma-Biotech, France, No. H20030577) once
monthly or 2.5 mg oral Gestrinone (Beijing Zizhu
Pharmaceutical Co., Ltd., China, No. H19980020)
twice a week. Patients treated with gonadotropin
releasing hormone agonist (GnRH-a) received addback
therapy of 1.25 mg Tibolone Tablets (Livial,
Nanjing Organon Pharmaceutical Co., Ltd., No.
H20051085) once a day after 4 months of treatment.
February 28, 2008, it had passed the ethic
review of the 11th Five Year Plan; August 21, 2008, it
had passed the ethic review of Guang’anmen Hospital,
China Academy of Chinese Medical Sciences for
changing clinical investigation plans.

Outcome Measures
The EMs recurrence rate, the pregnancy rate
and the incidence of adverse reactions were recorded.
Evaluations of dysmenorrheal, chronic pelvic pain,
menstruation conditions and the degree of adverse
reactions were based on “Guiding principle of
clinical research on new drugs of traditional Chinese
medicine.”(9) The incidences of dysmenorrheal,
chronic pelvic pain, menstruation and any adverse
reactions were recorded once a month during the
preoperative and postoperative periods and once
every 3 months during the follow-up period. Patients
underwent preoperative, postoperative and posttreatment
evaluation of safety indices including
type B pelvic ultrasonography, measurement of
serum CA125 levels, gynecologic examinations, and
routine evaluations of blood, urine, hepatic function
[glutamate pyruvate transaminase (GPT) levels],
renal unction [blood urea nitrogen (BUN) levels]
and electrocardiograms. During the follow-up period
they underwent type B pelvic ultrasonography,
measurement of serum CA125 levels and further
gynecologic examinations.

Evaluation Criteria
The diagnosis of recurrence was made by
referring to a manual on the diagnosis and therapy of
endometriosis. These were as follows: (1) recurrence
and aggravation after postoperative symptoms had
been relieved for 3 months; (2) the pelvic signs
returned after disappearing or were aggravated to
the preoperative level; (3) after operation, the type
B ultrasound scans showed a new focus of infection
or EMs; (4) The serum CA125 level increased again
after declining and other diseases were excluded. The
patients had a diagnosis of recurrence, fi tting one of the
criteria (2–4) above with or without concomitant criteria.
The three-point scoring criteria for adverse reactions
were as follows: (1) mild (1 point): minimal reaction,
work and life activities were unaffected; (2) moderate
(2 points): light reaction, work and life activities were
affected but could be tolerated; (3) severe (3 points):
severe reaction, work and life activities were badly
affected and could not be tolerated.

Statistical Analysis
The data were analyzed using SPSS 12.0
software (SPSS Inc., Chicago, IL, USA). Comparison
of the recurrence rate between two groups was
performed using χ2 test and the relative risk (RR),
odds ratio (OR) and the 95% confidence intervals
(CI) were calculated. The difference of count data or
measurement data between groups was compared
by Student’s t-test or χ2 test, respectively. Statistical
signifi cance was assumed at P<0.05.


General Clinical Data
The demographic data of the patients inChin J Integr Med 2013 Nov;19(11):820-825 • 823 •
both groups was shown in Table 1. There was no
difference of the baseline characters between the two

Comparison of Recurrence Rates
There were 64 patients (60.4%) received a
3-month treatment and 42 patients (39.6%) received
a 6-month treatment in the CM group. While in the
WM group, there were 51 patients (50%) received a
3-month and a 6-month treatment, respectively. The
mean follow-up time after operation in the CM group
was 20.66±6.75 months and 20.83±6.65 months in
the WM group with no statistical difference between
groups (P>0.05). There were no statistically signifi cant
differences in the clinical recurrence rate or in the time
to recurrence of pelvic EMs between the CM and WM
groups (P>0.05, Tables 2 and 3).

Comparison of Pregnancy Rates
A comparison of the pregnancy rate between
the two groups during the follow-up period showed no
significant differences (31.1% vs . 28.4%, P =0.670).
For those diagnosed with infertility before the
operation, the pregnancy rate in the CM group [12/15
(80.0%)] was signifi cantly higher than that in the WM
group [4/15 (26.7%), P=0.003]. The mean duration to
achieving the first pregnancy after the operation for
the patients in the CM group was also significantly
less than that in the WM group (P<0.05, Table 4).•


Table 1. Demographics of Patients in the Two Groups
Item CM (106 cases) WM (102 cases) Statistics P-value
Basic material Age (x–
±s, year) 32.52±6.16 31.70±6.08 0.97 0.33
Sexual life history [Case (%)] 84 (79.2) 80 (78.4) 0.02 0.89
EMs course (x–
±s, year) 28.80±36.82 38.15±56.07 –0.40 0.69
Clinical manifestation [Case (%)] Algomenorrhea 60 (56.6) 63 (61.8) 0.57 0.45
Chronic pelvic pain 42 (39.6) 37 (36.3) 0.25 0.62
Irregular menstruation 15 (14.2) 11 (10.8) 0.54 0.46
Infertility 15 (14.2) 15 (14.7) 0.01 0.91
Pelvis positive sign 101 (95.3) 96 (94.1) 0.14 0.71
Abnormal B-Ultrasound Scan 100 (94.3) 99 (97.1) 0.93 0.33
Abnormal CA125 49 (46.2) 52 (51.0) 0.93 0.63
Postoperative diagnosis [Case (%)] Ovarian endometriosis cyst 100 (94.3) 97 (95.1) 1.37 0.50
Deep infi ltrating endometriosis 6 (5.7) 4 (3.9)
Incorporation 0 (0.0) 1 (1.0)
r-AFS staging [Case (%)] StageⅠ 13 (12.3) 8 (7.8) 6.36 0.10
StageⅡ 51 (48.1) 43 (42.2)
StageⅢ 36 (34.0) 35 (34.3)
StageⅣ 6 (5.7) 16 (15.7)
CM Syndrome differentiation [Case (%)] Cold stagnation cause qi blockage 4 (3.8) 10 (9.8) 3.92 0.14
Qi stasis cause blood stagnation 69 (65.1) 68 (66.7)
Qi defi ciency cause blood stagnation 33 (31.1) 24 (23.5)

Table 2. Comparison of the Clinical Recurrence
Rates of Pelvic Endometriosis between
the Two Groups
Group Case Recurrence
[Case (%)] χ2 P-value RR (95% CI)
CM 106 9 (8.5)
1.448 0.229 0.619
WM 102 14 (13.7) (0.280–1.366)

Table 3. Comparison of the Time to Recurrence of
Pelvic EMs between Groups
Group Case
Time to recurrence (Month)
t P-value
±s Median (Range)
CM 9 8.56±4.93 6.00 (3.00–18.00)
–0.42 0.68
WM 14 7.86±3.08 6.00 (3.00–12.00)

Table 4. Comparison of the Time to First Pregnancy
between the Two Groups
Group Case
Time to fi rst pregnancy (Month)
t P-value
±s Median (Range)
CM 33 5.88±4.18 4.00 (1.00–17.00)
–2.09 0.04
WM 29 8.44±5.34 6.00 (3.00–21.00)

Comparison of the Incidence of Adverse
During the treatment period, there were
patients with adverse reactions in both groups. A
few patients in the CM group complained of mild
stomach upsets but these were relieved quickly after
adjusting the herbal medicines and dosages. Most of
the patients in the WM group showed some prolonged
adverse reactions, such as mild to moderate fever
and sweating, colpoxerosis, hypaphrodisia, acne,
weight gain, insomnia, bone pain, irregular bleeding,
headache and skin itching. There was a statistically
significant difference of adverse reactions between
the two groups [9.4% vs. 83.3%, P<0.01).

Comparison of Safety Indices
Before treatment, the safety indices and
biochemical parameters of patients in the two groups
were within normal ranges. After treatment, some of
these were outside normal ranges but there were no
statistically significant differences between the CM
and WM groups.

The pelvic pain and infertility caused by EMs
seriously affects the health and quality of life and
brings great pain and suffering to the patients.
Conservative operation is the choice of treatment for
young patients with EMs who wish to have a child, but
the recurrence rate remains persistently high. How
to delay or eliminate such recurrence is an important
research topic.
GnRH-a treatment causes a significant reduction
in the ovarian secretion of estrogen and leads to a
temporary cessation of menstruation, so it is called
reversible medical oophorectomy. At present, it is the
most effective Western medical treatment for patients
with EMs. Some authors have argued that the treatment
of EMs by combining a conservative operation with
GnRH-a therapy could reduce the recurrence rate
and increase the pregnancy rate.(10) However, others
recommended combining a conservative operation with
GnRH-a treatment for 3–6 months and following up
for 6–60 months. Comparing the above-mentioned
treatment with the expected treatment, there was
no statistically significant in the recurrence rate.(11-13)
Combined treatment with GnRH-a after operation
could increase the pregnancy rate but there was no
statistically significant difference in the pregnancy
rate.(10,14) The adverse reactions of GnRH-a treatment
mainly manifest as a low estrogen syndrome
with fevers, sweats, colpoxerosis, hypaphrodisia,
headache, insomnia, poor memory, emotional lability,
depression, debility, arthralgia, irregular vaginal
bleeding, breast haphalgesia and allergic responses.
Some patients of child-bearing age even develop
irreversible premature ovarian failure after treatment.
It is diffi cult for patients to accept these side effects. In
addition, the loss of bone mass is a serious adverse
reaction of GnRH-a, even with short-term treatments.
Because of the high-cost of GnRH-a, a
cheaper drug gestrinone has become a common
medicine to prevent the recurrence of EMs after a
conservative operation for EMs. Gestrinone inhibits
endometrial growth to control the recurrence of
EMs, and has antiestrogenic, antiprogestogenic
and antigonadotropic hormone effects. Treatments
with gestrinone and GnRH-a are both effective in
controlling recurrence and increasing the pregnancy
rate, but gestrinone induces adverse reactionsdue
to the high androgenic hormone levels.(15) The best
time for pregnancy is 6 months to 1 year after an
operation for EMs. However, during treatment with
WM, the patients cannot get pregnant, so it is easy
to miss the optimal time.(16) For those patients with
infertility before the operation, there is a need to use
assisted reproductive technologies to increase the
pregnancy rate after stopping drugs. However, this is
burdensome to the patients.
By contrast, treatment with Chinese herbal
medicines stresses prescription for the individual
patient’s syndrome pattern and attempts to adjust
the body’s physiology holistically. The recurrence
rate of EMs following treatment with CM in this study
was basically identical to treatment using WM. At
the same time, it had some advantages, such as
not interfering with the patient’s normal physical
condition. It produced a low incidence and mild
symptoms of adverse reactions and showed good
patient compliance. During treatment with CM, the
patients could also try to get pregnant. The time to
first pregnancy among the patients in the CM group
was shorter than that in the WM group, especially for
those patients diagnosed with infertility caused by
endometriosis before the operation. The effectiveness
of raising the conception rate of patients in the CM
group was obviously better than in the WM group.Chin J Integr Med 2013 Nov;19(11):820-825 • 825 •
In this study, syndrome differentiation and
treatment with CM has provided a new investigative
direction and treatment for controlling the recurrence
of EMs after a conservative operation. It also improved
the general condition of the patients, improved the
conception rate and helped them to select the best
time to get pregnant. Thus, it is appropriate for general
use in the clinical treatment of patients with EMs.
International registration number: ChiCTRTRC-

1. Giudice L, Kao L. Endometrosis. Lancet 2004;364:1789-1799.
2. Garry R. The effectiveness aflaparoacopic excision of
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3. Lang JH. Notes of gynecological surgery. Beijing: China
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different drugs. J Pract Med (Chin) 2008;24:3741-3743.
11. Jee BC, Lee JY, Suh CS, Kim SH, Choi YM, Moon SY.
Impact of GnRH agonist treatment on recurrence of ovarian
endometriomas after conservative laparoscopic surgery.
Fertil Steril 2009;91:40-45.
12. Loverro G, Carriero C, Rossi AC, Putignano G, Nicolardi
V, Selvaggi L. A randomized study comparing triptorelin or
expectant management following conservative laparoscopic
surgery for symptomatic stage Ⅲ-Ⅳ endometriosis. Eur J
Obstet Gynecol Reprod Biol 2008;136:194-198.
13. Porpora MG, Pallante D, Ferro A, Crisafi B, Bellati F,
Benedetti Panici P. Pain and ovarian endometrioma
recurrence after laparoscopic treatment of endometriosis: a
long-term prospective study. Fertil Steril 2010;93:716-721.
14. Rickes D, Nickel I, Kropf S, Kleinstein J. Increased
pregnancy rates after ultralong postoperative therapy
with go in releasing hormone analogs in patients with
endometriosis. Fertil Steril 2007;78:757-762.
15. Zhang L, Qu XD, Jing FR. Comparison of clinical
effect of different drugs in treatment of endometriosis
after laparoscopy operation. Chin J Clin Pharm (Chin)
16. Chen F, Ma CL. GnRH-a in treatment of endometriosis
research progress. Chin J Birth Health Heredity (Chin)
(Received January 14, 2012)
Edited by YUAN Lin

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