Does acupuncture improve the prospects forconception?

鍼灸は不妊に効果があるのか？
Taiken Jo 1,3(徐 大兼), Reina Taguchi 2(田口玲奈)
1 Acura Acupuncture Clinic (Japan)
2Department of clinical Acupuncture and Moxibustion, Meiji University of Integrative Medicine (Japan)
3Fertility Acupuncture Network (Japan)

Background• One in seven couples suffer from infertility and many will seek help
in the form of assisted reproductive technology (ART).
• The use of acupuncture in the improvement of conception is still
controversial.
• Cochrane Report in 2013 showed that use of acupuncture inparticipants undergoing assisted conception treatment around thetime of embryo transfer or at egg collection in terms of improving
the live birth rate, ongoing or clinical pregnancy rate showed noevidence of benefit.
• These controversial results have led The British Fertlilty Society tochange its guidelines on acupuncture following an announcementthat it had found no evidence that having acupuncture or Chinese
herbal medicine treatment around the time of assisted conception
increases the likelihood of subsequent pregnancy.

Objective• To extract problems inherent in 2013 Cochrane
Report by analyzing the design of the study,
pa@ent background, methodology anddiﬀerences in the results of the acupunctureinterven@on.

Study Design and Setting• Twenty randomized controlled trials were included of which fourof the trial reports were abstracts. Nine studies were excluded.
• 14 studies are done around ET.
• It has been shown that the recep@vity of the endometrium and theuterine contrac@on frequency at the @me of ET are cri@cal for embryo
implanta@on.

• 6 studies are done around Oocyte retrieval• Of which one study was done con@nuouslyStudy CharacteristicsAcupuncture Method
Timing20 RCT Studies

Before AQer Embryo Transfer

14 (3632 women)

Before Transfer: Neiguan, Diji, Taixi etc
AQer Transfer: Zusanli, Sanyingjiao, Xuehai, Hegu

Oocyte Retrieval

5 (876 women)

LFEA: 30 min before retrieval on Hegu, Waiguan, Guilai, Zusanli, Sanyingjia

Con@nuous Treatment

1 (44 women)

EA 4 @mes, twice a week on Taichong, Sanyinjiao, Shuidao, Zicong, Qihai,Guanyuan

At or around the ,me of Embryo Transfer
MethodPaulus/2002

Acupucture
Germany+EarBAET
Before,AQerEmbryoTransfer

3○N/A

N/AN/A

N/A

N/A

nodiﬀerence inpulsa@lity
index

Smith/2006

Austrailia

Acupucture+Ear

D9＋BAET

3×

N/A

×N/A

N/A

N/A

N/A

Dieterle/2006

Germany

Acupucture+Ear

PT30min＋
PT3

2○○○

N/A

○×

N/A

BAET＋PT2

1○

N/A

×

N/A

N/A

×N/A

4×

N/A

N/A

N/A

N/A

N/A

reducedstressWestergaard/2006 Denmark
Domar/2009

USSo/2009

Hong
Kong

Jadad
Score

ResultTiming ofInterven@on

Author/Publica@on
CountryYear

Clinical Biochemical Ongoing Live Birth Implanta@on Miscarriage
Rate
Rate
Pregnancy Pregnancy Pregnancy
Rate5×

N/A××××

reduc@on in
endometrial
vascularity,reduced cor@sol
and anxiety

2×

N/A×××

N/A

N/A

5×N/A

N/A×××

N/A

Acupuncture

Madaschi/2010

BrasilAndersen/2010 Denmark

BAET

others

So/2010

Hong
Kong

5X

N/Axx

X

N/A

N/A

Moy/2011

US

5××

N/A

N/A

N/A

N/A

N/A

Points Used

EX
CA1
K11 TE5
SP10 ST 28
Liv 3
LI 10 LU 7 SP 6
ST 36 PC 6 RN 3 RN 4Zigo
SP 8
ST 29
RN6 K3
Cv 6 DU 20
LI 4
Shous Liequ Sanyi
Xueha Shuid
Zusha Neigu Zhong Guany
Hengg Weigu
Taich+D5:DijiQihai Taixi
Qi Hai Baihui
GuilaiHegu
hanli e njiao
iaonlian
jiuanuanong
W18ng

Paulus/2002

xx

Smith/2006
Dieterle/2006

xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx

Westergaard/2006

xxx

Domar/2009

xxxSo/2009

xxxxxxxMadaschi/2010
So/2010
Moy/2011
Paulus 2003
Carig 2007

xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx

Paulus 2002 vs Domar 2009 vs So 2009
Paulus 2002

Domar 2009

So 2009noyes

yesPregnancy rate

42.5% vs 26.3%

42% vs 47%

38.9% vs 49.2%

Overall Pregnancy

Unknown

Unknown

35% 2005

Embryo Quality

GoodGood

UnknownPlaceboAcupuncture Points Used
16141313
12101010832

111222211

Acupuncture on and around the day of ET (No Sham/Needling)
Clinical Pregnancy
69.6%
54.7%

44.0%

40.4%

32.2%

42.5%
26.3%

43.8%

37.6%
24.1%

Acupuncture n=853

51.5% 50.3%
30.8% 33.8%

Acupuncture on and around the day of ET (sham/needling)
Clinical Pregnancy
52.7%
45.3%

43.0%
37.0%

33.6%

31.2%

34.9%
32.2%

49.2%
38.9%

44.2%
36.3%

22.9%
15.6%

DIETERELE 2006+
PAULUS 2003+
SMITH 2006+
ANDERSEN 2010MOY 2011

Acupuncture n=1876

SO 2009
Control (sham/needling)n=1020SO 2010

Overall Outcome
Clinical Pregnancy
42.8%
39.1%

38.7%
36.1%
NO SHAMSHAM (PLACEBO)
Acupuncture n=1876

37.5%

36.6%

OVERALL

Control n=1756

P=0.55 Acupuncture does not improve pregnancy
rateOocyte Retrieval
Clinical Pregnancy Rate
Author/Publica@on
CountryYear

MethodTiming ofInterven@on

ResultClinical
Biochemical Ongoing
Pregnancy Pregnancy Pregnancy

Live Birth Implanta Miscarriage
Rate @on Rate
Rateothers

N/A

×

Reducedstress, pain
VAS

Stener-Victorin/
1999

BOR
Electroacup
Before Oocyte
SwedenunctureRetrieval

Stener-Victorin/
2003

Electroacup
Swedenuncture

BOR

×N/A

×

N/A

N/A

×

Reducedstress, pain
VAS, Nausea

Humaidan/2004

SwedenElectroacup
uncture

BOR

×

N/A

N/A

N/A

N/A

N/A

Reducedpain VAS

Gejevall/2005

Electroacup
Swedenuncture

BOR

Electroacup
SatorAustrailia
Katzenschager/2006
uncture/EA

BOR

×N/A

N/A

○×N/A

N/A

N/A

N/A

N/A

Reducedstress, pain
VAS

○N/A

N/A

N/A

N/A

N/A

Reducedstress, pain
VAS, Nausea

Oocyte Retrieval
Clinical Pregnancy Rate
46.9%

37.3%
32.5%
30.0%
28.8%
28.6%
25.3%
23.3%

Acupuncture n=478

46.6%50.0%

Control n=434

30.5%33.8%

P=0.53 Acupuncture does not improve pregnancy
rate30.5%
30.0%
29.5%

Mul@ple Acupuncture
Treatments D2～OR 4 @mes

（twice a week)
Liv 3, SP 6, ST 28
EA 30 min

30.0%

29.0%
28.5%

28.6%

28.0%
27.5%
Acupuncture n=30

Control n=14

Ho 2009
Ho M. Taiwan J Obstetrics and Gynecology 2009;48(2):148–51.

From Cochrane 2009 Repeated acupuncture

P=0.00059 Acupuncture improves pregnancy rate
However, not enough number and needs further consideraSon

Eﬀec,veness of acupuncture for fer,lity
1. Change in uterine blood ﬂow and uterine contrac@lity( eﬀects
are due to a central inhibi@on of the sympathe@c ac@vity)
2. Relaxa@on of Stress
3. Eﬀect on the HPO, HPA axis

Variables Which Affect The Outcome Of IVF
体外受精の結果を左右する因子• Egg Quality (卵子の質）• Sperm Quality（精子の質）• Embryo Cul@va@on Environment（培養環境）• Endomitrium（内膜の状態）• Embryo Quality （受精卵の質）• Implanta@on Method （移植方法）• Other factors (その他の因子）

Variables Which Affect Oocyte Quality
卵母細胞の質を左右する因子• Ovarian Assessment (AMH, Bologna Criteria, Diminished OvarianReserve)（卵巣の評価）• S@mula@on Methods (Agoinst, Antagonist, Long, Short, Kato
Method )（刺激法）• Trigger @ming (Oocyte Maturiza@on)（トリガー 成熟卵）
• Oocyte Aspira@on Methodolgy（採卵方法）

Author/PublicaSon Year

Assisted ConcepSon Protocol

Paulus/2002

N/A

Smith/2006

N/A

Dieterle/2006
Westergaard/2006
Domar/2009
So/2009
Madaschi/2010
Andersen/2010
So/2010
Moy/2011
Paulus 2003
Carig 2007
Fraterelli 2008
Benson 2006
Stener-Victorin/1999
Stener-Victorin/2003
Humaidan/2004
Gejevall/2005
Sator-Katzenschager/2006
Ho/2009

Standard, long, FSH, hMG
Standard, long, FSH, hMG
N/AStandard, long, FSH, hMG
Standard, long, FSH, hMG
Standard, long, FSH, hMG
Standard, long, FSH, hMG
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Standard, long, FSH, hMG
N/AN/AVariables Which Affect Sperm and Oocyte
Quality（精子と卵子の質を左右する因子）• Lifestyle• Alcohol/Cigareqes• Stress• Exercise• Age• Chromosomal Aberra@on• Fresh or Frozen

Embryo Cultivation Environment
培養環境• Cul@va@on Medium（培養液）• Incubator（インキュベータなど、培養環境）• Skill of Embryologists（培養士の技能・経験）Endometrium（子宮内膜環境）• Thickness（内膜の厚さ）• Immune Tolerance・Implanta@on Failure（免疫寛容・着床障害）• Endometrial Recep@vity• Cilia, Pinopode (シリア・ピノポード）• Vascularity• Vasucularity Index（血管の量）• Flow Index（血流の速さ）• Vascularity Flow Index(血流量）• Endometrial Volume（内膜の容積）

Embryo Quality（受精卵の質）• Embryo Grading （受精卵の評価法）• Day 3 Embryo Grading (cell size, fragmentation)• Day 5 Embryo Grading (Inner Cell Mass, TrophectodermEpithelium )• Very Early Blastocyst, Expanded Blastocyst, Hatched Blastocyst

Implantation Method （移植法）• 4-Cell, 8-Cell, Morula, Blastocyst（４分割、桑実胚、胚盤胞）• Implanta@on Window (Natural vs Controlled)（着床の窓、自然周期、ホルモン補充周期）• Frozen vs Fresh （新鮮胚、凍結胚）• Hormone Supplementa@on（ホルモン補充の有無）

Other factors（その他の因子）• Age 年齢
• Previous treatment history 不妊治療歴• Oocyte retrival and Embryo transfer history(採卵歴及び移植歴）• BMI

Outcome of IVF…Not Just Acupuncture

ＩＶＦの結果を左右する因子、、、鍼以外に沢山ある• There are several variables that affect the outcome of IVF（体外受精の結果に影響を与える因子が多数存在）• In order to assess the true efficacy of acupuncture, further
consideration necessary.（鍼の真の効果を測定するには、それらの因子の扱い方に注意が必要）Quality Improvement of Oocyte
卵母細胞の質の向上• How long should it take to improve the qualityof Oocyte theore@cally? （質の向上をために、どれぐらいの期間を要するのか？）Folliculogenesis
卵胞形成過程Folliculogenesis
卵胞形成過程Discussion• How can we successfully measure the effectiveness ofacupuncture in reproductive medicine?（鍼の効果を確実に測定する方法とは？）
1.
2.
3.
4.

Endometrial Plasticity
Immune Tolerance
PGD/PGS (Aneupolidy, Chromosomal Aberration)
Finding optimum control (Placebo/Sham)