A Snap shot of IVF Acupuncture Research over the past 15 years, and why DOSE is key to optimising outcomes.

I am Amy Forth, an acupuncturist with more than 10 years’ experience who is passionate about helping couples trying to conceive naturally or through IVF. As someone who is very interested in fertility and women’s health issues, I gravitated almost immediately to working in clinics that focused in it.  I love working in this area because it has so much to offer.

As a practitioner, I am keen to address the most recently published study by WSU and IVF Australia into the effectiveness of acupuncture in relation to IVF success. This study created a media response, such as an article by the conversation “Acupuncture during IVF doesn’t increase chances of having a baby”.  The research that has just been published does not however reflect clinical results, nor some of the other IVF and acupuncture studies published in recent years and I want to provide some information on why this is the case.

I maintain, although acupuncture was not found to have a significant effect on live birth rates for IVF patients in this study,  that I am glad the recent study on acupuncture and IVF by researchers has come out. Why? It shows us what dose of acupuncture doesn’t work.

What did the study measure?

In a nut shell, the study measured the effectiveness of three treatments over two days. One treatment was given before embryo transfer (ET) and two more on the same day as ET.  Effectiveness was measured by live birth rates for the group given acupuncture in comparison to a group that was not.  You can find out more about the research here.

 The acupuncture and IVF journey 

ET acupuncture treatments became very popular from 2003 onwards, after the Paulus Study 2002 showed promising results in increased pregnancy rates. In that study clinical pregnancy rates were 42.5% in the acupuncture group, whereas pregnancy rate was only 26.3% in the control group.

The Paulus finding, and others that followed, were no doubt a reason why clinics like the Acupuncture Pregnancy Clinic initially opened, however acupuncture on day of transfer was never all that was recommended. Our clinics and others like us of course did and still do offer acupuncture on the day of embryo transfer and use treatment protocols based on Paulus 2002 original research. However, the clinics also mirrored other IVF research in which it had became clear that what Traditional Chinese Medicine had to offer IVF patients was so much more than ET acupuncture.  As new research continued to emerge, The Acupuncture Pregnancy Clinic treatments and recommendations evolved. The benefit of a higher dose of acupuncture quickly became apparent to practitioners and their patients, as the clinic began to recommend that patients focus on treatment before and during the IVF cycle.cropped-acupressure-for-fertility-points1.jpg

 Is acupuncture a magic bullet?

As this study found…well no.

Acupuncture, quite like IVF, is far from a magic bullet. It is however a therapy that changes physiology over time. Usually a course of treatment is required for lasting or significant effect.  For example, it has also been shown to induce neurotransmitter release, which activates certain pituitary hormones that increase ovulation, and improve menstrual regularity and overall fertility (1).  In addition acupuncture has been well documented to reduce stress by its ability to raise endogenous opioid levels (2).  In fact, based on more current research, I would go as far as to say the Paulus 2002 study was unusual in that it showed an effect of just two acupuncture treatments, when most acupuncture research, outside of IVF and acupuncture research scope, would usually study the effect of a course of acupuncture treatment that ranges between approximately 8-16 treatments. This is because  the dose of the acupuncture matters.

CLINICAL PRACTICE SUGGESTS ACUPUNCTURE DOSE MATTERS

What I see clinically,  is that to help my patients and really bring about change – dose really matters. And of course, it does. Would you take three pills out of a course of medication that usually requires twelve pills and expect it to have significant and lasting effects? Acupuncture is no different. It’s NOT a magic bullet but a therapy that needs to be administered in the correct dose for the presenting condition and is unlikely to be effective if it is not.  This is supported by a lot of acupuncture research in diverse areas. Some of which I have been lucky to be a part of as a practitioner.

So how do we know what correct dose is?

Well here are a few studies that found a reasonably large dose was required…. the ones related to IVF patients that I like the most are by Hullender Rubin et al, 2014 and Magarelli et al, 2009.

Stener-Victorin, 1996  also made a similar observation, a full course of treatment was needed for an effect. They found that acupuncture improved Ovarian Blood Flow after eight treatments and this was maintained at follow up four weeks later. Similarly, research on hormone levels such as that by Jedelet al, 2011 showed that low frequency EA (electro-acupuncture) decreased testosterone and regulated menstrual cycles after 16 weeks of treatment. Johansson et al, 2013 found that Acupuncture increased ovulation frequency in PCOS patients with 10-14 weeks of treatment 2x/week. A cumulative dose Trial  “Treating primary dysmenorrhoea with acupuncture” found providing ≤3 treatments did not appear to show a trend towards reduced pain compared to those with >3 treatments for immediate, short-term or long-term outcomes. This study concluded – needle location, number of needles used and frequency of treatment show clear dose-response relationships with menstrual pain outcomes. While this finding did not relate to fertility outcomes, it highlights the impact of dose and  the relationship that dose has to therapeutic outcomes.

Conversely several studies found ET acupuncture alone had no statistical advantage Shen C et al, 2015  and  Manheimer E et al, 2013  on its own,  however Shen C et al, 2015 noted acupuncture administered during the IVF cycle stimulation phase and/or during implantation phase in addition to treatment at the time of transfer showed significant improvement in pregnancy rates. The finding of improved pregnancy rates when acupuncture was administered before and or during the IVF stimulation phase was reiterated by systematic review and meta-analysis of  Qian Y et al, 2016,  Zheng CH et al, 2012  and Zhang et al 2018.

The Hullander research is probably what I draw on most  

Hullander’s research showed that acupuncture administered to IVF patients at a dose of 9-12 visits prior to embryo transfer is associated with more live births. Lee Hullender Rubin and her colleagues analysed the outcomes of more than a thousand IVF cycles and found that women who used Chinese Medicine (acupuncture with or without herbs, dietary advice etc.), had a higher live birth rate than those doing IVF alone. The proportion of live births was  61.3% in the Chinese Medicine group  and 48.2% in the usual IVF care  group and 50.8% in the group having acupuncture only on day of embryo transfer.  The whole systems approach I like as it is mirrors what is likely to occur  in the clinic.  This is the approach we take at The Acupuncture pregnancy clinic now and there is a fair bit of other research to back it up. For more on examples of higher dose acupuncture favouring increased pregnancy rates click here.

What about this recent study?

As participants in this study were only given three acupuncture treatments, I think it falls short of the dose needed to have a significant therapeutic effect.  While previous research has found effect with 2-3 treatments, this research concluded that effect was not significant and perhaps put to bed the idea that this dose does have a significant effect on IVF live birth rates.

I think it is important we don’t conclude that acupuncture for IVF and  fertility does not have a significant effect. Instead we note that this study showed that just three treatments may not significantly increase IVF success to such an extent that it may affect live birth rate.

So what do I think, where do we go from here?

It is time to re-examine what acupuncture dose means and how it works (or doesn’t work). Although some of acupuncture’s effects are quick, more commonly they are cumulative in order to make significant and lasting changes.

In a nutshell –  Acupuncture is a therapy that works via administering a therapeutic dose. As this study highlights, acupuncture is not a magic bullet. It is however a very valuable therapy that has an effect when administered in the correct way and in the correct dose.belly ACUIVF

 Author Amy Forth would like to acknowledge and thank Jane Lyttleton for all her help and contributions.
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 Amy Forth  BHSc (TCM) MGHDS (Global Health)

Is Director and Acupuncture Practitioner at The Acupuncture Pregnancy Clinic Alexandria, located in Alexandria Specialist Day Hospital (alongside IVF Australia)  and Amy Forth Acupuncture, Randwick.  Amy has a passion for womens health, fertility and making acupuncture accessible and mainstream part of health care. Amy is also a global health, and integrative medicine researcher and recently completed a Masters of Global Health. The topic of her research was “The Culture of Biomedicine: A significant barrier to General Practitioners’ access to and communication of Complementary and Alternative Medicine information.”


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