Effects of Acupuncture on Rates of Pregnancy and Live Birth Among Women Undergoing In Vitro Fertilization: Systematic Review and Meta-Analysis

In vitro fertilization is expensive, lengthy, and stressful; thus, new techniques have been developed to improve success rates, but few have proven effective. Acupuncture, as an adjuvant treatment to embryo transfer, has been suggested as amethod to improve pregnancy and live birth. To evaluate the potential efficacy of acupuncture, the authors conducted this large-scale, systematic review and meta-analysis of all randomized, controlled trials comparing needle acupuncture administered within a day of embryo transfer with sham acupuncture or no adjuvant treatment. Data sources includedMedline, Cochrane Central, Embase, and theChineseBiomedicalDatabase—from inception to January 2007—plus hand-searched abstracts, the proceedings of 3 major annual conferences on assisted reproduction technology from 2001 to 2006, and reference lists of all eligible reports. To be eligible, a trial had to report data on at least one of these outcomes: clinical pregnancy, ongoing pregnancy (beyond 12wk gestation), or live births. Only trials involving the insertion of needles into traditional meridian points were included (exclusions were dry needling, trigger-point therapy, laser acupuncture, and electro-acupuncture without needle insertion). Authors of eligible reports—especially those with abstracts only—were contacted for additional information on design and outcomes. The measure of treatment effect was the pooled odds ratio of achieving one of the major outcomes in the acupuncture group compared with controls. All meta-analyses were based on the number of women randomized, with the intention-to-treat approach. Subgroup analyses included generation and concealment of allocation sequence, blinding of patients and physicians, loss to follow-up, and intention-to-treat analysis. Whether effects of acupuncture varied with 3 clinical characteristics that might influence success—extra acupuncture sessions, eligibility restricted to women with good quality embryos, and low versus high rates of clinical pregnancy in control groups—was also assessed. Seven trials with a total of 1366 subjects, conducted in 4 different Western countries, met inclusion criteria; all were published in English since 2002 in 2 of the leading reproductive medicine journals. Four were full reports; 3 were abstracts. Unpublished data were obtained for all. All trials had generally sound methodology, including typical clinical populations and use of typical interventions before and after randomization. Subjects encompassed a wide range of ages, diagnostic categories and duration of infertility, and numbers of previous treatment cycles. Two trials included only women with good quality embryos. In all trials, the acupuncture protocol was designed for the sole purpose of improving rates of pregnancy, fixed selection of points were similar (all but one), sessions lasted 25 to 30 minutes, and women received acupuncture immediately before or after the embryo transfer. There were no significant differences in the mean number of embryos transferred. Embryo transfer with acupuncture was associated with a higher incidence of clinical pregnancy (odds ratio, 1.65; 95% confidence interval, 1.27-2.14), ongoing pregnancy (1.87; 1.40-2.49), and live birth (1.91; 1.39-2.64) than occurred among controls. Among subgroup analyses, only the one on rates of clinical pregnancy in the control group showed a significant effect modification (P=0.04). Restriction to the 3 trials with the highest rates of clinical pregnancy in the control group suggested a smaller, nonsignificant benefit of acupuncture. No significant adverse effects of acupuncture were reported in the two trials providing that information. Overall, acupuncture increased the odds of clinical pregnancy by 65%; and, in absolute terms, the number needed to treat was 10. This suggests that acupuncture improves the rates of pregnancy and live births among womenundergoing in vitro fertilization. Limitations of this meta-analysis included heterogeneity of baseline rates across trials, the potential for publication and orientation biases, the possibility of ‘‘hypothesis’’ or interpretive bias, and the inclusion of three studies presented only as abstracts. The authors note that biases cannot be excluded, but the potential is likely to be minimized because of the objective outcome measures and the methodologically sound study designs, and sufficient additional outcome and study design information obtained from the authors of the abstracts. Considering safety and cost, large, prospective surveys of practitioners show that serious adverse effects are rare following acupuncture. Plus, because of the possibility of increasing the rates of successful outcomes, the relatively inexpensive technique of acupuncture looks very good compared with repeated cycles of in vitro fertilization. Epidemiologic Reports, Surveys Obstetric Anesthesia Digest Volume 28, Number 3, September 2008