Volume 8, Number 3 | Fall 2013

Japanese Acupuncture - Current Research
Japanese Traditional Medicine Text (9) – Obstetrics
Hiroaki Suzuki

alleviation of pain at delivery, as well as acupuncture
anesthesia for caesarean section, and subsequentcase reports but no RCTs, so it is difficult to say that
there are any papers with a high evidence level at[Chapter 4 Clinical Acupuncture and Moxibustion p217]

the moment. Among that research is a comparative

1. Introduction

study by Yasuda et al. on alleviation of pain at

A search of MEDLINE for research literature on

delivery using acupuncture anesthesia claiming thatclinical acupuncture and moxibustion in obstetrics

electro-needling at Zusanli and Sanyinjiao achieved

overseasandpain alleviation in all 18 primipara and 83% of the‘acupuncture’ obtained 195 results. Some researchpara (12)2). While it has drawbacks, including theinto acupuncture anesthesia in obstetric surgery wasfact that the effects of acupuncture anesthesia varycarried out in the 1970s, then from the 1980s a few

among individuals and that movement is limited forstudies examined analgesia for contractions andthe pregnant women, it does demonstrate alleviationdelivery, correction of fetal breech presentation andof anxiety in pregnant women owing to alleviation ofanalgesia for caesarian section. There are also

pain, shortening of the course of labor, and some

papers on treatment of morning sickness andreduction in the amount of bleeding. It is also safe

dysmenorrhea. Much clinical research has examinedand simple, making it a method of alleviating pain

acupuncturewithat delivery with no complications. Additionally,

assisted reproductive technology (ART), typically in-Tsujiuchi has published a comparative study onvitro

acupunctureusing

theandfertilization,terms

moxibustion
with‘obstetrics’

associatedpapersaddressing

improvement of uterine blood flow, alleviation ofandmoxibustion

forbreech

presentation3).

pain associated with ovum collection, as well as
improvement of pregnancy rates. While infertility[Chapter 4 Clinical Acupuncture and Moxibustion p218]

and breech position are addressed in detail below,

Mizumoto et al. reviewed 10 papers on low back pain

three quarters of the 195 papers were publishedand pelvic pain in pregnant women in a meta-after 2000, suggesting acupuncture and moxibustion

analysis of the safety of acupuncture and its

have attracted much attention in obstetrics over theanalgesic effects, finding in all papers significant

last 10 years. Focusing on randomized controlleddecreases in low back pain and pelvic pain during

trials (RCTs), the results include 39 papers on

pregnancy compared to the control group, andobstetrics (12 on contractions and delivery, 6 on ART,

finding no adverse event in either mother or

6 on morning sickness and hyperemesis, and 5 on

newborn.

peripelvic pain, 4 on breech presentation, 2 on

The topic will now turn to obstetric acupuncture

mastitis, and 4 on other topics including failure ofandmoxibustion

lactation, caesarian section, climacterium, andpresentation.

forinfertilityandbreech

premenstrual tension). Most of the papers are fromEurope, which accounted for 60% of the total,

2. Acupuncture and moxibustion for infertility -including 11 papers from Sweden. A meta-analysis1)

Overseasof contractions suggests that acupuncture may beOverseas researchers have published a number of

useful for alleviating labor pain, however, the sample

studies into the question of whether acupunctureis small, therefore further research is required.

improves the rate of pregnancy by ART, including anClinical obstetrical research in Japan includes a

RCT by Paulus (2002), as well as studies by Smith

paper by Kakizaki et al. in 1973 on labor induction,(2006), Dieterle (2006) and Westergaard (2006). As

2The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

Volume 8, Number 3 | Fall 2013of 2010, the results of 3 meta-analyses had been(3) Stress alleviation: While it has been reported thatpublished. According to Manheimer et al. (2008), 7stress has an impact on infertility, acupuncture canRCTs showed that the odds ratio of clinical gestation

be expected to ease stress by stimulating thein women who received acupuncture was 1.65, theproduction of endogenous opioids.

rate of ongoing pregnancy (more than 12 weeks) in 5of them was 1.87, and the live birth rate in 4 was

Before acupuncture and moxibustion

1.91, thereby finding significant improvement in thegroups receiving acupuncture and moxibustion ineach of the RCTs5). Further, Cheong et al. (2008)
found in 13 well-designed studies that the live birthrate odds ratio for women who received acupunctureon the day of embryo transfer was 1.89, suggesting
it is effective6). However, El-Toukhy et al. (2008)
found that in 5 studies in which acupuncture wasperformed around the time of ovum collection the3-layer structure

5 mmThree months after acupuncture and moxibustion

clinical gestation risk rate was 1.06; the clinicalgestation risk rate was 1.23 in 8 studies in which
acupuncture was performed around the time ofembryo transfer; and the live birth risk rate was 1.34
in 5 of the 8 studies, thereby finding no significant
difference

attributabletoacupuncture

andmoxibustion in any of the studies7). Thus, while
researchers

havefoundthat

acupuncture

isbeneficial, some studies found no effectiveness, so
further research is required.

1-layer structure

9 mm

Six months after acupuncture and moxibustion

Acupuncture’s mechanisms of effect
The following are some possible mechanisms ofeffect in acupuncture for the female reproductivesystem.
(1) Effects on the endocrine system: Acupuncture canbe expected to affect the menstrual cycle,
ovulationandgestation

byregulating

the3-layer structure

discharge of neurotransmitters and stimulating
GnRH excretion.

8 mmFigure 1: Typical transvaginal ultrasound images of a(2) Improvement of uterine blood flow: StenerVictorin found that electro-needling improved

case of endometrial improvement
Beforeacupunctureandmoxibustion

endometrial

vascular resistance in uterine arteries between

thickness is thin (5 mm), making embryo transfer impossible,

in-vitro fertilization and embryo transfer. This

however, 6 months after acupuncture and moxibustion, theeffect is thought to be attributable to theendometrium has grown to a 3-layer structure and 8 mm,

suppression of sympathetic nerve activity.

which meets the criteria for embryo transfer thereby allowing
embryo transfer.

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

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Volume 8, Number 3 | Fall 2013

After endometrial improvement, gestation was

3. Acupuncture for infertility - Japan
Although no RCTs have yet been published inachieved in 14 (45.1%) of the 31 patients whoJapan, Shimizu et al. published a comparative study

received freeze-thaw embryo transfer. Furthermore,on the “effects of acupuncture on the menstrual cycle

repeating ART cycles achieved high rates ofand glycometabolism in women with ovulatory

endometrial condition improvement (2nd cycle: 75%,disorder”8). The following are some of the effects of

3rd cycle: 60%) and gestation (2nd cycle: 44.4%, 3rd

acupuncture and moxibustion for infertility we havecycle: 66.7%). These results suggest acupuncture

published.

and(a) Acupuncture and moxibustion combined withendometrial condition and contribute to an increase

freeze-thaw embryo transfer in 57 patients within gestation rates.

moxibustionareeffectiveinimproving

endometrial misshaping and replication study(51st & 52nd Congresses of the Japan Society ofUterine artery RI

Uterine radial artery RI

Before acupuncture After acupuncture

Before acupuncture After acupuncture

and moxibustion

and moxibustion

Acupuncture and Moxibustion).
Acupuncture and moxibustion were performed fora defined period on 57 patients with intractable
infertility, after failing to achieve gestation with atleast 3 attempts at ART, and the endometrium
failing to meet the defined criteria for formation
thereby precluding freeze-thaw embryo transfer
despite at least two attempts at endometrialpreparation with hormone replacement therapy.
Patients’ patterns ( 証 ) were determined by pulse
location and quality diagnosis ( 脉 位 脉 状 診 ),abdominal examination (腹診), and interview, andthe casual or essential treatment ( 本 治 法 ) were
performed in addition to local or symptomatictreatment ( 標 治 法 ) at Guanyuan, Zhongji, Dahe,Xuehai, Sanyinjiao, Shenshu, Ciliao and symptombased selection of other acupuncture points. An
electro-moxa device was used on the abdomen andindirect moxibustion was performed at the low to
mid back and legs (low back: Shenshu, baliaoxue,legs:Sanyinjiao,Yongquan,Shimian,etc.).

Endometrial preparation with a repeated cycle ofhormone

replacement

acupuncture

andwasperformed

moxibustion,

afterresulting

inendometrial condition improving to the defined
criteria (3-layer structure of at least 6 mm) in 31(54.4%) of the 57 patients (see Figure 1).

and moxibustion

Figure 2: Change in uterine and uterine radial artery RI
before and after Zhongliao needlingTransvaginal color Doppler was used to measure vascular
resistance on the 3rd-7th day of menses and acupuncture wasperformed once a week for an average between 7 and 15 times(mean: 9.4). Measurements were repeated on the 3rd-7th dayof the second menses after acupuncture commenced. Uterine
artery RI decreased in 8 out of nine cases, while the mean also
decreased significantly from 0.87 to 0.80 (p=0.011). Utene
radial artery RI decreased in at least half, demonstrating adownward trend in the mean from 0.81 to 0.77, however, thiswas not statistically significant.

4and moxibustion

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

Volume 8, Number 3 | Fall 2013

[Chapter 4 Clinical Acupuncture and Moxibustion p219]

and 1 meta-analysis. In 1998, Cardini conducted an(b) Impact of needling Zhongliao on uterine

RCT in China on the “effects of moxibustion forarterial circulation in infertile patients (51stcorrection

Annual Meeting of the Japan Society for

primipara in the 33rd week of pregnancy and a

Reproductive Medicine)

control group of 130. The method involved theFaced with the need to attempt new therapies for

pregnant women themselves applying stick moxa atcases in which our usual therapies have not resulted

Zhiyin, resulting in cephalic version in 75.4% of thein gestation, we turned our attention to the bladder,treatment group and 47.4% in the control group,

another organ within the pelvis along with thewhich was a significantly high rate of version in theuterus and ovaries. Because needling Zhongliao istreatment group. However, the study was criticized

effective in urology for lower urinal tract symptoms

for a lack of randomization and placebo. In 2004,

such as overactive bladder and prostate enlargement,

Neri published the results of an RCT with 226

nocturnal enuresis, as well as chronic pelvic pain

pregnant women showing breech presentation in thesyndrome with venal stasis in the pelvis9), we trialed

33th to 35th week of pregnancy, achieving significant

Zhongliao

of itsresults with needle retention and stick moxibustion.

effectiveness on the pelvic organs, for infertility

More recently, in November 2009, Guittier et al.

patients.

published an RCT with 212 pregnant womenneedling,

withthepromiseofbreech

presentation”

with

130

Our method of needling Zhongliao involved

showing breech presentation in the 34th to 36th weekretaining stainless disposable needles (0.3 mm inof pregnancy. Their method involved performing

diameter, 60 mm long) at about 60 mm depth, thenmoxibustion at Zhiyin and the patients themselves

manual stimulation at left and right for a total of 10

applying moxa at home, which achieved nominutes, with the patient in prone position. Aftersignificant result. The numerous studies to date

performing acupuncture at Zhongliao only for ashow the rate of version is low if initial consultation

definedis in the 34th week or later.

periodon9infertility

patients,

measurements of vascular resistance using color

In September 2009, Vas et al. published a meta-Doppler showed a significant decrease in the uterine

analysis of 6 studies up to June 200710). It covered

artery resistance index (RI) from 0.87 to 0.80, and a

1,087 pregnant women showing breech presentation

decrease in the RI for the uterine radial arteries inand compared groups in which moxibustion was

at least half, although the decrease from 0.81 to 0.77

performed and control groups in which treatment

was2).

other than moxibustion was performed. The results

Furthermore, gestation was achieved in 4 of the 8

showed that while the rate of version was 72.5% forpatients who received freeze-thaw embryo transfergroups in which moxibustion was performed, theafter acupuncture.

rate was 53.2% in control groups (relative risk: 1.36,

notstatisticallysignificant(Figure

confidence interval: 1.17-1.58). Vas et al. concluded
4. Acupuncture and moxibustion for breech
presentation - Overseas
In the 1980s, after Yoshiro Hayashida performedthat moxibustion performed at Zhiyin (BL67) wasmoxa needling at Sanyinjiao and moxibustion at

5. Acupuncture andpresentation - JapanZhiyin to treat breech presentation and showed itseffective.
moxibustionforbreech

conducted RCTs of acupuncture and moxibustion for

Sakago no Shinkyu Chiryo (Acupuncture andMoxibustion for Breech Presentation), written andbreech presentation. Searching MEDLINE using theedited by Shuichi Katai11), reports 14 of the Japaneseterms “acupuncture” and “breech” results in 10 RCTs

publications on acupuncture and moxibustion for

great

benefits,

variousoverseas

researchers

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

5

Volume 8, Number 3 | Fall 2013breech presentation since World War II in Japan,6. Issues in clinical obstetric research

however, not one of them was a randomized study. Of

From an ethical perspective, making comparisons

the total 1,663 cases covered, correction waswith no-treatment groups in a clinical acupuncture

achieved in 1,382. So, while the rate of correction

and moxibustion scenario is difficult and shamwas 83.1% across all type of the cases, the rate ofneedling has not yet been clearly defined, whichcorrection in each type varied between 11.7 andsuggests that further good-quality studies, not just

92.3%. Of the total 210 cases in which treatment

RCTs, must be undertaken. The issue for the future

started during weeks 32 to 35, when it becomes moreis how to go on disseminating truly useful clinicaldifficult for the fetus to change position naturally,

research from Japan.

correction was achieved in 136 (64.76%). In regard totreatment methods, while many of the publications

Referenceused Zhiyin and Sanyinjiao, they varied in terms of1)

Smith CA: Complementary and alternative

their methods, types and frequencies. Other than 4

therapies for pain management in labour.

cases of nausea and blistering or pigmentation

Cochrane Database Syst Rev Oct 18; (4),caused by moxa, no serious symptoms were observed

Australia, 2006

that could be attributed to acupuncture and2)

Kenta Akira: Experiences of Pain Relief

moxibustion stimulation in the 1,363 cases that did

duringmention adverse events.

Anesthesia.

[Chapter 4 Clinical Acupuncture and Moxibustion p220]

The first to use moxibustion at Zhiyin for breech3)

4)

pregnancy:Abirth among women undergoing in vitro
fertilization: systematic review and meta ─analysis. BMJ 336(7643): 545-549, 2008
6)

Cheong YC, Hung Yu Ng E, Ledger WL:
Acupunctureandassistedconception.

Cochrane Database Syst Rev Oct 8; (4):CD006920, 2008

been, for example, a case control study. The author
andduringof acupuncture on rates of pregnancy and live

possible if it finds benefit for patients, even if it had
acupuncture

Pain5) Manheimer E, Zhang G, Udoff L, et al.: Effects

high level as an RCT, it makes the practice of EBM

thatPelvic

School of Therapeutics 33: 198-202, 2010

evidence, it is not equivalent to an RCT or meta-suggests

BreechLiterature Study. Journal of the Oriental

The author says that while in terms of its level ofthereforefor

Ayako Mizumoto, Minami Kazunari, Satoko
andmedical concepts.”

rather than insisting that the evidence must be as

Acupuncture

Nakagomi et al. Acupuncture for Low Backthe history of acupuncture and moxibustion to use

analysis, if you take EBM as the starting point,

gynecology

9(1): 65-70, 200920 patients. … This paper appears to be the first inpresentation, which is defined according to WesternandPresentation. Modern Acupuncture Studies

treat breech presentation was effective in 16 out ofacupuncture and moxibustion to treat breech

Obstetrics

Acupuncture

Keiko Tsujiuchi: Treatment for Women`sConditions:delivery was the obstetrician and gynecologist Ishino
findings in 1950 that moxibustion at Sanyinjiao tousing

treatment 91(2) 227-230, 2005

presentation during pregnancy rather than atNobuyasu. It is said that “Ishino published hisDelivery

7)

El - Toukhy T, Sunkara SK, Khairy M, et al.:moxibustion for breech position is an effective, safe,

A systematic review and meta ─ analysis ofand comfortable treatment that should be widely

acupuncture in in vitro fertilisation. BJOG

used.

115(10): 1203-1213, 2008

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Volume 8, Number 3 | Fall 2013

8)

Yoji

Shimizu,

KuniakiNiwa,

KazamiNakazawa et al.: Effect of Acupuncture for
Irregular

Menstrual

CycleandGlucose

Metabolism in Women with Anovulation. The
Japanese Society of Balneology, Climatology
and Physical Medicine 73(3)292-211, 2010
9)

Hisasi H, Kamoi K, Naya Y, et al.: Effect ofacupuncture for chronic pelvic pain syndromewithintrapelvic

venouscongestion:

preliminary result. Int J Urol 11: 607─ 612,2004
10) Vas J, Aranda JM, Nishishinya B, et al.:Correction of nonvertex presentation withmoxibusiton:

asystematicreview

andmetaanalysis. Am j Obstet Gynecol 201(3):241─ 259, 200911) Shuichi

Katai(editor):Acupuncture

Treatment of Breech Presentation: Studyingin Illustrations and Photographs. Ishiyaku
Publishers, Tokyo, 2009

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

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