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Journal of the Association of Chartered Physiotherapists in Women’s Health, Autumn 2008, 103, 29–38
CLINICAL PAPER
The use of acupuncture with in vitro fertilization: is
there a point?
J. Longbottom
Private Practice, St Neots, Cambridgeshire, UK
Abstract
This paper presents a Western biomedical model of acupuncture and a traditional
Chinese medical (TCM) approach to the use of this technique within in vitro
fertilization (IVF) in one private practice. The author demonstrates the underlying
mechanisms of introducing an acupuncture protocol as a means of preparing
women for IVF, both physically and emotionally, by enhancing optimum
endometrium conditions, increasing uterine blood flow, and supporting the
embryo pre- and post-IVF intervention. Acupuncture can also support men in
terms of enhancing the quality, motility and viability of sperm, and providing
emotional support throughout the process.
Keywords: acupuncture, fertility, infertility, in vitro fertilization.
Introduction
Infertility is not confined to the female, but Infertility can be defined as the inability to regardless of whether it manifests in either or conceive following one year of unprotected inter- both partners, it is associated with significant course. This condition affects nearly 15% of all mental trauma, and imposes serious financial couples who are trying to have a baby: Evers constraints on those undergoing assessment (2002) reported that approximately one in every and treatment. This process is stressful, can be six couples have trouble with conception.
costly and imposes a physical strain upon the Although the following list is by no means reproductive system, especially in the female.
exhaustive, the causes of infertility may be Reported statistics vary, but it would seem that broadly categorized into eight major groups around 30% of men are sub-fertile and at least 2% are totally infertile; furthermore, there ismuch scientific debate concerning the evidence that male fertility is decreasing markedly as a (2) anatomical abnormalities leading to the result of modern lifestyles. It has been estimated obstruction of sperm transportation, or the that about 9% of the UK’s 28.5 million men might have difficulty impregnating their partners through the reproductive tract (i.e. tubal, uterine, cervical and peritoneal factors); In vitro fertilization (IVF) is the most success- (3) abnormalities in the implantation process, ful of the various forms of infertility treatment, including early defects in embryo develop- and for many, it may be the last hope of becom- ment, embryo abnormalities and borderline ing pregnant. Practitioners are advised to offer no expectations of success because the failure rates of IVF are high and patients bring enor- mous expectations to the treatment. Some 35 261 (6) body weight, smoking, alcohol and caffeine IVF cycles were performed in the UK in 2006, but on average, the success rate of IVF per single initiated cycle (using a fresh, non-donor oocyte) is only 33% (CDCP 2003) and the majority of Correspondence: Jennie Longbottom, Parks Therapy Centre, IVF cycles do not result in pregnancy (Rosenthal 86 Cambridge Street, St Neots, Cambridgeshire PE19 1PJ,UK (e-mail: jennie@alied.co.uk). & Anderson 2007). Because of the high financial  2008 Association of Chartered Physiotherapists in Women’s Health and emotional cost of this procedure, many were significantly higher in the acupuncture group (P<0.01). The acupuncture group main- alternative medicine, and there is now a prolifer- tained serum levels of progesterone and pro- ation of patient self-referrals for acupuncture as lactin, as well as the protein and messenger well a world-wide increase in the number of ribonucleic acid expression levels of progester- acupuncture clinics offering this therapy as one receptors and prolactin receptors (P<0.05), an adjunct to IVF procedures (Rosenthal & suggesting that acupuncture may help to sustain Anderson 2007). Within the present author’s progesterone levels regardless of hormonally own practice, self-referrals have doubled in the adverse environmental factors, such as high doses of oestrogen in water supplies (Warhurst China to regulate the female reproductive system Margarelli & Cridennda (2004a) investigated via the stimulation of qi and blood, and by prolactin and cortisol levels in patients receiving regulating homeostasis (Maciocia 1997). Within acupuncture during an IVF cycle. Both prolactin the Western model of acupuncture, the potential and cortisol levels increased; elevated hydro- mechanisms of needling may mediate the release cortisone levels in follicular fluid have been of neurotransmitters that can in turn stimulate shown to improve pregnancy rates. In a previous secretion of gonadotropin-releasing hormone study, the above authors found a statistically (GnRH), and therefore, assist ovulation, blood significant (42%) increase in ongoing preg- flow and fertility (Mayer et al. 1977; Anderson nancies, as well as a statistically significant et al. 2007). Several studies have examined the reduction in the number of miscarriages and mechanisms of action. Richer & Ford (2001) ectopic pregnancies (Margarelli et al. 2004b).
demonstrated that endometrial thickness may be All the above studies reinforce the idea that one factor in pregnancy outcomes. Yu et al.
correct point selection according to the infertility (2007) studied the effect of acupuncture on pattern diagnosis, correct timing and admin- uterine lining when combined with sildenafil istration of acupuncture, and obtaining a sub- (Viagra). Although this was only a pilot study, stantial de qi response consistently improve all four subjects achieved an increase in endo- pregnancy outcomes. Because of the potential metrial lining from <8 mm to >10 mm following for negative effects as a result of improper acu- acupuncture and sildenafil, including one patient puncture administration, it is prudent to utilize who had not responded to sildenafil alone. The acupuncturists who have demonstrated compe- above authors hypothesized that effects on the tency and knowledge in reproductive medicine; endometrium could be stimulated by a resulting indeed, the normal standards in the USA dictate increase in the supply of nitric oxide synthase, that all acupuncture practitioners undertake which contributes to transmission from one the American Society of Oriental Reproductive neuron to another, to the immune system and to The IVF and acupuncture procedure involves Liu et al. (2007a) investigated the effect of several phases, all of which require careful co- acupuncture on implantation by studying at ordination, experience, and above all, working three groups of rats: a control group; rats treated at all times with the IVF team. Those without only with mifepristone, which is used as an knowledge of fertility, infertility and the physio- abortifacient in the first 2 months of pregnancy; logical processes of acupuncture, or those with- and a group treated with both mifepristone and out adequate liaison with fertility carers and the acupuncture. The rats that received mifepristone team members should not consider it.
plus acupuncture had the same implantation The present paper is intended to introduce rates as normal rats. The mifepristone-only physiotherapists to the use of acupuncture within the management of IVF. It is not meant (P<0.01), providing further evidence of the abil- to offer a prescription for intervention, or ity of acupuncture to reverse certain chemotoxic encouragement for physiotherapists to use this agents that may be contributing to infertility technique without adequate training, knowledge and insurance. This paper is presented in order Liu et al. (2007b) followed the above study to demonstrate the present author’s experience with another in which they measured a number of clinical practice, in which she uses a combined of serum parameters; namely, pregnancy rates approach to acupuncture within IVF. The views and the average number of blastocysts, which and protocols used in this example are not  2008 Association of Chartered Physiotherapists in Women’s Health Acupuncture and in vitro fertilization definitive, and no attempt has been made to a reduction in egg quality and quantity; poor critically appraise all research cited, present the endocrine readings, caused by high levels of methodology for each infertility protocol or give follicle-stimulating hormone; reduced blood flow preference to one protocol over another.
and cervical mucous secretions; and low oestro-gen levels and less-frequent monthly ovulations(Jansen 2003).
The phases of in vitro fertilization
The IVF process involves several phases that
Western evidence for clinical reasoning must be carefully coordinated and precisely Neurophysiological research has provided evi- timed. The phases involve several protocols, dence that acupuncture treatment regulates which may include the use of oral contracep- neurotransmitters and increases the secretion of tives, GnRH agonists and uterine blood flow GnRH, as well as increasing blood flow by impedance measurements. These protocols vary inhibiting uterine central sympathetic nerve and are constantly being refined by collabora- activity (Stener-Victorin et al. 1996), and stimu- tions between women, clinics and physicians lating the production of endogenous opioids by (Rosenthal & Anderson 2007). The debate con- inhibiting the central nervous system outflow and biological stress responses (Cho et al. 1998).
according to experience, training and TCM pat- What is intriguing is that, unlike most other disease processes within gynaecology, where The main phases are outlined for guidance either inflammation or degeneration are the only; constant liaison with the consultant and major presentations, we are now faced with the IVF team is essential for an integrated changes within the patient’s normal bodily hor- monal balances, which calls for a greater degreeof clinical reasoning within our acupuncture Phase I: Hormonal down-regulation
approach. Within Western evidence-based medi- Most commonly, an oral contraceptive is used, cine, we rely on the function of the hypothala- followed by GnRH (Lupron) to inhibit ovula- mus, anterior pituitary and ovaries in the tion. In theory, the ovaries are rested in prep- production of oestrogen and progesterone to effect endometrial changes. Within TCM philos-ophy, the yin and yang phases of the normalmenstrual cycle have a profound effect on point selection and pattern identification, and should Within the present author’s practice, acupunc- ture is not only offered pre- and post-embryotransfer (ET), but also for the preparation of thefemale and, if necessary, the male. The latter is Traditional Chinese medicine clinical regarded as essential before IVF dates are agreed with the multidisciplinary team. The diagnoses Within TCM, the diagnosis relies on the balance of infertility are extensive; the following list between blood and qi in the uterine cavity, the details common presentations at the present supply of Kidney (KI) qi to the uterus itself, and the smooth action of blood in Spleen(SP) and Liver (LV) meridians supplying the fallopian tubes, ovaries and endometrium. Bal- ance, harmony and homeostasis are required to offer the best possible opportunity for IVF and successful implantation. Therefore, treatment will be directed towards improving qi and blood flow to the relevant meridians [i.e.
Advancing female age is an important factor points. These points have a particular action on in low pregnancy outcomes (Gindoff 2008).
meridians by means of increasing the flow of qi Problems affecting women attempting pregnancy and blood to their named meridian, rather like at the age of 40 years and above include: a the opening of a lock gate. The present author is decrease in fertility rates of approximately 50%; presently engaged in research using Doppler a two- to threefold increased risk of miscarriage; ultrasound to investigate the action of He-sea  2008 Association of Chartered Physiotherapists in Women’s Health Table 1. He-sea acupuncture points to supply the pelvis: (L) lumbar segment; and (S) sacral segment
Increases pelvic and genital blood and qi; points on blood flow to the pelvic viscera (Table1). The ST, SP, LV and KI meridians all flowthrough the pelvic basin, and are essential to thestimulation of qi and blood flow to the pelvis(Fig. 1).
Associated points are used to calm the patient, help sleep and nourish the meridians that supplythe pelvis in an effort to restore homeostasis,reduce stress and facilitate ease of implanta-tion during this phase (Table 2). Patients aretreated twice a week until their stress levels aremore manageable and relaxation techniquesare being practised regularly with good effect.
The use of hypnotherapy and cognitive behav-ioural therapy referrals is recommended if acu-puncture intervention is not offering sufficientstress reduction.
Patients are encouraged to acupressure the He-sea points and stimulate blood flow via thefemoral artery with gentle arterial massage.
Figure 1. Pelvic meridians.
Table 2. Suggested ‘calming’ acupuncture points to aid relaxation and sleep: (L) lumbar segment; and (S) sacral segment
Activates the Kidney, Spleen and Liver channels; Used with heat to invigorate circulation, qi and blood to the uterus  2008 Association of Chartered Physiotherapists in Women’s Health Acupuncture and in vitro fertilization Table 3. Normal values for semen analysis (Clavey 2003)
Table 4. Suggested acupuncture points for blood and qi stimulation of sperm production: (L) lumbar
segment
Stimulation of kidney qi;stimulation of sperm production He-sea points stimulating liver, qi and blood He-sea points stimulating spleen, qi and blood He-sea points stimulating stomach qi and blood Recent research has shown that Viagra trig- Acupuncture and TCM offer a large propor- gers and accelerates the acrosome reaction in tion of infertile men not only hope, but a sperm, stimulating the premature release of clear improvement in sperm count, motility, ‘egg-penetrating’ enzymes – which are produced morphology and liquefaction (Clavey 2003) in order to break down the outer layer of the egg – and therefore, preventing adequate egg Male infertility has been identified as a prob- penetration on arrival. This poses a problem lem for over 50% of childless couples in the UK.
when Viagra is used in fertility clinics (over half Although the causes are too numerous to discuss of UK fertility clinics use Viagra to promote within the scope of the present paper, the more semen production; New Scientist 2008).
common presentations within the author’s prac-tice are: Once hormonal down-regulation is about to + blocking of the epididymis, vas deferens or begin, the treatment strategy must be tailored to the goals of the IVF team and the medications that are prescribed. During this period, the ovaries are allowed to rest and Lupron is used to prevent ovulation; this may cause a deficiency of qi and some pain in the pelvis. Table 5 lists the points that Liang (2003) suggested should beused to treat patients experiencing side effects The appropriate treatment and selection of points will depend upon accurate diagnosis ofthe presenting condition. For a general tonifica-tion of blood and qi, the points listed in Table 4 Phase II: Ovulation induction
are recommended before sperm storage. Treat- Gonadotropin-releasing hormone drugs are used ment is offered daily as soon as the female to stimulate multiple follicles depending on age and ovarian function. Oestrogen and luteinizing sperm specimen results are necessary to deter- hormone levels are measured, follicular develop- ment is tracked by ultrasound and dosages  2008 Association of Chartered Physiotherapists in Women’s Health Table 5. Suggested acupuncture points for down-regulation
patient provides the following results at each attendance in order to determine whether further acupuncture treatment is desired or the protocolchanged: (1) Endometrial thickness scans. These scans Liver (LV) and Large Intestine (LI) LV3, LI4Extra points endometrium should be at least 7–8 mmthick for implantation of the egg and is an adjusted accordingly, and just before ovulation indicator of progesterone levels. Acupunc- occurs, human chorionic gonadotrophin (hCG) ture point Tituo is identified as a strong qi is injected 33–35 h before oocyte retrieval to growth is poor, then using the Zigong and While hCG stimulates multiple follicle produc- Ear Ovary points may be beneficial should tion, acupuncture can support blood flow in the endometrial thickness be slow to develop.
pelvis and improve response to medication (3) Oestrodial levels. If readings are above (Rosenthal & Anderson 2007). The points men- 5000 pg/ml early in the cycle, daily acupunc- tioned in Table 4 may be used again, but often ture is required to lower this level of oestro- with the addition of Lung 7 and KI6 to open dial. Points such as ST40, LV2 and LV3, and the Extra Vessel or Chong Mai, and SP4 and Pericardium 6 to open the Extra meridian or Penetrating Vessel (Liang 2003). This treatmentoften requires three to four sessions, twice a Phase III: Pre-embryo transfer
The suggested treatment interval for acupunc- ture prior to ET is 30–40 min (Stener-Victorin & is a potentially serious side effect at this stage.
Humaidan 2006), and thus, practitioners and Mild OHSS may result in ovarian enlargement, patients are required to offer flexibility in ap- and abdominal pain, nausea and vomiting; the pointments and treatment availability (Table 6).
latter symptoms may be alleviated by acupunc-ture. Severe OHSS requires immediate attentionand/or surgical intervention. The first clinical Phase IV: Oocyte retrieval
Retrieval is performed under local anaesthetic thirst, and therefore, it is essential that the and the oocytes are transferred for laboratory Table 6. Pre-embryo transfer points (Paulus et al. 2003)
Regulates pelvis;nourishes uterus;calms the patient  2008 Association of Chartered Physiotherapists in Women’s Health Acupuncture and in vitro fertilization Table 7. Acupuncture protocol 2 days after embryo transfer (Paulus et al. 2003)
storage. Women often experience discomfort similar to deep menstrual pain during oocyte used, especially in the maturity of dominant retrieval; this is caused by the needle passing follicles, which increases the chances of contain- ing a mature egg and producing a viable embryo.
oocytes. Electro-acupuncture (EA) has been Chinese herbal medicine can be used to maintain used to induce fast-acting opiate stimulation for corpus luteum function by increasing the size analgesia, and studies have reported that EA can and vascularity of oocytes. This is important in bring about reductions in both pain and side preventing miscarriage in the first 10–12 weeks effects at this stage (Stener-Victorin et al. 1996).
of pregnancy, when all progesterone comes fromthe ovaries and corpus luteum; the placenta only fully takes over this function at 3 months (Heese Oocytes are graded for maturity and cultured for 3–6 h before exposure to sperm. Sperm aregraded and incubated overnight, and checkedfor signs of fertilization. The embryos are Phase VI: Post-embryo transfer
allowed to grow to the six- to eight-cell stage of Patients are required to rest in the lying position development (i.e. 3 days) before implantation.
whilst acupuncture is applied post-ET in thepresent author’s own practice. This protocol was Phase V: Embryo transfer
cited by Paulus et al. (2003), who studied 160 Embryos are once again graded and implanted patients who received either acupuncture 25 min before and after ET (n = 80), or a standardregime of only bed rest 25 min after ET (n = 80).
Traditional and auricular acupuncture points Progesterone is given to support the endo- were used in the treatment group (Table 8). The metrium and a pregnancy test is conducted 14 clinical pregnancy rate of 42.5% in the acupunc- days after implantation. If the pregnancy test is ture group versus 26.3% in the control group was positive, it is advisable to reduce the intensity of significantly in favour of the former (P = 0.03).
de qi stimulation and avoid such points as SP6 Paulus et al. (2003) further recommended a third and Large Intestine (LI) 4. These are considered arm to future trials involving placebo needles cautionary points (AACP 2007), although there to rule out the possibility of psychological or is no clinical or scientific evidence to support this psychosomatic effects in the acupuncture group.
view (Roemer 2005). Indeed, a number of these points have been used in IVF trials without impetus for further studies (Smith et al. 2006; obvious adverse effects or changes in live birth Westergaard et al. 2006; Dieterle et al. 2008) weight, but please note the discussion of these and a systematic review (Manheimer et al. 2008).
results below (Westergaard et al. 2006).
The latter authors concluded that acupuncture Immediately after conception and for the next given with ET improves rates of pregnancy 12–14 weeks, acupuncture may be used to sup- outcome data on live births that was not avail- although Chinese herbal medicine (CHM) may able at the time of the study by Paulus et al.
be more effective. Wing & Sedlmeier (2006) (2003). Although the current estimates of the noted that fertility markers improved as much in effects of adjuvant acupuncture on IVF are both  2008 Association of Chartered Physiotherapists in Women’s Health Table 8. Post-embryo transfer points (Paulus et al. 2003)
Regulates pelvis;nourishes uterus;calms the patient significant and clinically relevant, these remain native medicine rely on anecdotes, from which somewhat preliminary (Manheimer et al. 2008).
peer reviewed case reports can be derived forpublication. These are essential and should beencouraged as a first step to robust research Discussion
A number of studies have investigated the poten- In all the trials cited above, the acupuncture tial of acupuncture to improve the outcome of protocol and selection of points were designed IVF (Vayena et al. 2002; Paulus et al. 2003; for the sole purpose of improving pregnancy Dieterle et al. 2006; Johnson 2006; Smith et al.
rates, and the point selection appears to have been based upon the first published trial (Paulus Westergaard et al. 2006), but these have only et al. 2003). Few studies have investigated the emphasized the use of acupuncture pre- and prolonged effect of acupuncture on both male post-ET. The relevant protocols are not analysed and female blood flow and stress management in the present paper because these are outside its procedures pre-IVF, or the influence of He-sea scope, and the reasons for variations in point points on pelvic blood flow, which could be choice and clinical reasoning are complex. Each applied as acupressure or transcutaneous electri- of the researchers mentioned above examined a cal nerve stimulation (TENS) by patients who particular field of interest to determine the effects had been instructed in these techniques.
If acupuncture does work by modulating the Stener-Victorin & Humaidan (2006) investigated balance of endogenous opioids, then burst- whether repeated acupuncture treatments given frequency TENS (2–4 Hz) applied by the patient over a period of 4 weeks exerted a general to the given points could safely, cheaply and inhibiting effect on uterine sympathetic tone, easily be offered, and is worth investigating thereby reducing high blood flow impedance in uterine arteries, and increasing uterine blood flow and hypothetical endometrial receptability.
employed in studies to date do not reflect clinical Despite this, acupuncture is still considered to practice. The dosages employed in many trials be suspect in many circles (Domar 2006; Myers were low (i.e. between one and nine sessions).
2006) and there have been claims that higher In clinical practice, acupuncture treatments pregnancy rates in acupuncture groups may be a occur over periods of weeks and even months result of placebo effects. Stener-Victorin & (Anderson et al. 2007). Traditional Chinese Humaidan (2006) suggested that, when debating medicine diagnosis was only discussed in one this and discussing how alternative treatments trial (Smith et al. 2006), and no protocols were have been scientifically tested, ‘one should real- tailored to deal with deficiencies or imbalances ize that many treatments in conventional medi- (Maciocia 1997). It appears that a similar proto- cine also lack rigorous testing, a failing that the col was used in most trials cited in the present scientific community generally acknowledges paper, and this is somewhat contrary to the must be remedied’. Both conventional and alter- clinical reasoning model taught in TCM and  2008 Association of Chartered Physiotherapists in Women’s Health Acupuncture and in vitro fertilization acupuncture within physiotherapy. A fixed pro- nerves (Lee et al. 2004) and LI4 is considered to tocol produces a fixed protocol bias, reducing cause cervical dilation (Ying 1985); therefore, the likelihood that the treatment will be appro- care, knowledge and clinical judgement must be priate and effective for all subjects.
employed whenever acupuncture is used to assist The IVF process is highly stressful, not only because of drug interaction and the financialimplications of the treatment, but also because itmay involve serious adverse effects in the form of References
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(2003) Placebo-controlled trial of acupuncture effects inassisted reproduction therapy. Paper presented at the Jennie Longbottom is chair of the Acupuncture 19th Annual Meeting of the European Society for Association of Chartered Physiotherapists, a Human Reproduction and Embryology, Madrid, 30 June member of the British Acupuncture Council and runs a private practice. She lectures at under- Richer S. C. & Ford W. C. L. (2001) A critical investigation graduate, postgraduate and MSc level. Her of NADPH oxidase activity in human spermatozoa.
Molecular Human Reproduction 7 (3), 237–244.
special interest is chronic pain, with a particular Roemer A. T. (2005) Medical Acupuncture in Pregnancy: A emphasis on chronic pelvic pain and complex pain Textbook. Thieme Publishing, Stuttgart.
 2008 Association of Chartered Physiotherapists in Women’s Health

Source: http://www.csp.org.uk/sites/files/csp/secure/acpwh103_08_theuseofacupuncture.pdf