Abstract

The use of acupuncture during in vitro fertilization (IVF) has been shown in clinical trials to significantly improve the chance of pregnancy. Since the publication of the first trial in 2002, the popularity of acupuncture as an adjunct therapy during IVF has increased steadily. Oriental medicine practitioners who specialize in fertility have significant numbers of patients who are undergoing IVF. This patient population has several defining features that greatly influence a practitioner's approach to treatment. Some of these directly relate to the integrated nature of the acupuncture treatments with the western medical interventions, and others relate to the psychosocial aspects of undergoing IVF. Knowledge of the recent clinical research investigating the ability of acupuncture to improve the outcome of IVF is important for an acupuncturist to know. Acupuncture treatment protocols can incorporate the approaches taken in the research trials and/or strategize treatments with regard to different phases of the IVF cycle.

Introduction

The use of acupuncture for women undergoing IVF is an excellent example of the growing trend in our profession to integrate acupuncture into western medical procedures. Chinese medicine has been used for thousands of years to treat infertility, and now in the 21st Century it is being used in a highly specific and strategic manner to improve the effectiveness of high-tech western fertility treatments. This represents a new application of acupuncture therapy, and as such requires new and different approaches and perspectives.

There are several aspects of acupuncture treatment for women undergoing IVF that have a major bearing on how to optimize the effectiveness of the treatments. These aspects are not reflective of how Oriental medicine (OM) practitioners usually decide upon effective treatment strategies. Most important is the fact that the acupuncture treatment must be carried out in conjunction with the anticipated or current western medical interventions. Knowing a patient's TCM diagnosis is not enough, also what has to be considered is the physiological impact of the western treatments. The second big consideration is the demographic characteristics of the patient population. Women undergoing IVF who seek acupuncture are usually aged mid thirties and above, highly educated successful professionals, and very knowledgeable about infertility, IVF, and research on adjunctive therapies and supplements. An acupuncture practitioner can expect to be asked a lot of questions, ranging from the technical aspects of the IVF medications and procedures to acupoints used in the recent acupuncture/IVF clinical trials. The ability of the practitioner to answer these questions and have a good working knowledge of all aspects of IVF will significantly affect the efficacy of the treatments.

The third important aspect is that women undergoing IVF often report high levels of stress, anxiety and depression, and these conditions lower their chances of becoming pregnant. IVF patients are obviously concerned about their ability to conceive a child, but there are other sources of stress. These most often include a changed perception of themselves and possibilities for their future. Feelings of inadequacy and deep sadness are common, as are anxiety about the future and losing time in terms of their age. Difficult alternative choices such as adoption, egg, and sperm donors are topics that many IVF couples consider after failed IVF cycles. IVF is also very costly (approximately $12,500 per cycle) and not covered by insurance in most states of the US. Consequently, many couples undergoing IVF are also experiencing financial pressures. Oriental medicine practitioners are usually also addressing these psychological aspects in their treatments. But it is not just the actual treatments that provide therapy for the psychological challenges of IVF, it is also the nature of the practitioner/patient relationship. The OM practitioner sees patients once or twice a week, in an atmosphere conducive to patient's being able to talk about their personal experiences and associated feelings. Oriental medicine practitioners are also an enormous help with allaying anxiety around the IVF procedures themselves by explaining these aspects and helping them with any decisions that they need to make.

The fourth important aspect is the side effects of the IVF procedures and medications, which most women undergoing IVF will experience to varying extents. These can be mild to severe, and in some cases life threatening. Chinese medicine can be very effective in reducing these side effects, and may be the main reason some women seek treatment.

An IVF Cycle

The IVF process has several phases that must all be very carefully coordinated and precisely timed. A diagram of the basic timeline is shown in Figure 1. In this article I will briefly explain the phases of the IVF cycle, more detailed descriptions are available in a prior publication1.

The IVF Protocol begins with hormonal suppression of ovulation and control of the menstrual cycle. This is followed by hormonal induction of the ovaries to produce multiple follicles. Five to twenty follicles may be produced, depending upon a woman's age and ovarian function. Just before ovulation would be occurring, the patient is given an injection of hCG (human chorionic gonadotropin), which induces ovulation. Thirty three to thirty five hours later the oocytes are surgically harvested (oocyte retrieval). This procedure is undertaken with local or general anesthesia. In the laboratory the oocytes are examined under a microscope and the most viable ones are selected for in vitro fertilization. The sperm may be introduced passively to fertilize the oocytes, or injected into the oocyte (intracytoplasmic sperm injection, ICSI). The fertilized oocytes (zygotes) are incubated for 3 - 5 days and develop into embryos. Two to three of the most viable embryos are selected for embryo transfer (ET), which involves inserting the embryos into the uterus via a catheter through the cervix. This procedure is usually done on an outpatient basis. The first pregnancy test is performed 14 days after oocyte retrieval. As the success rate per IVF cycle is about 33%, most women undergo 3 to 6 IVF cycles before becoming pregnant.1

IVF Side Effects

As previously mentioned, IVF is a stressful process emotionally and financially. In addition, there are physical stresses from t he procedures and medications. These range from tenderness at hormone injection sites to a range of physiological side effects associated with the changed hormonal milieu. There is a great deal of variation in how women feel during IVF, some are fine, whilst others suffer a great deal. Some of the more common side effects that occur throughout the various stages of IVF are as follows.

During the suppression phase common side effects include hot flashes, night sweats, emotional sensitivity, insomnia, depression, headaches, decreased libido, bloating, and fatigue. During ovulation induction, patients can experience depression, irritability, headache, abdominal or pelvic pain or pressure, bloating, weight gain, and fatigue. Immediately following oocyte retrieval some women experience abdominal pain. In the second part of the IVF cycle following retrieval women may experience bloating, dizziness, depression, breast tenderness, headache, abdominal pain and distention, nausea, and irritability.

The most serious risk of IVF is ovarian hyperstimulation syndrome (OHSS). This occurs due to the hyperstimulation of the ovaries to produce multiple follicles. Mild symptoms include abdominal tenderness and bloating. A small percentage of women with large numbers of follicles have significantly elevated estrogen levels, which causes the ovaries to become enlarged. Severe symptoms include acute pelvic pain, swelling of the hands or legs, shortness of breath, weight gain, low urine output, diarrhea, and nausea or vomiting. Severe OHSS can be fatal so it is crucial to get prompt medical attention to a patient experiencing such symptoms.

Recent Clinical Trails

There have been several studies investigating the use of acupuncture to improve the outcome of IVF2,9. The highest quality and most conclusive studies are the six randomized controlled trials (RCT) that specifically addressed the hypothesis that acupuncture can improve the outcome of IVF3,4,5,6,7,8. A detailed analysis of these studies has been presented in several previous publications1,2,9.

Three of the RCTs3,4,6 present evidence suggesting acupuncture can significantly improve the success of IVF. Paulus and colleagues (2002)3 compared the clinical pregnancy rate of two groups of subjects, one who had received acupuncture 25 minutes before and 25 minutes after embryo transfer and the other that had no acupuncture intervention during IVF. The group receiving acupuncture had a clinical pregnancy rate of 42.5% compared to 26.3% in the nonacupuncture group.

This same basic acupuncture treatment protocol (with some modifications) was used in the two other studies. Dieterle et al (2006)4 investigated the effect of real and sham acupuncture. The group that received real acupuncture, as compared with the sham group, had significantly higher ongoing pregnancy rates (28.4% vs 13.8%). Westergaard et al (2006) 6 compared subjects that had not received acupuncture with those that received acupuncture immediately before and after ET, and another group who received an additional acupuncture treatment 2 days post ET. Ongoing pregnancy rates were receiving acupuncture immediately before and after ET as compared with controls (36% vs 22%), but not for the group who received the additional acupuncture treatment 2 days post ET.

Acupuncture Treatment During An IVF Cycle

Thus far, research has mainly investigated the use of acupuncture in the very narrow window before and after ET. There have been no clinical studies investigating the use of acupuncture in preparation for IVF or a detailed investigation of acupuncture during the stages of IVF. Thus, in clinical practice, one may choose to stick to the well-documented Paulus (2002) 3 protocol and do acupuncture only before and after ET. Or one may prepare the body for IVF by beginning acupuncture three months or more ahead of IVF and continuing throughout the stages of IVF. A diagram of the stages of IVF and proposed acupuncture treatments is shown in Figure 2. These point protocols are a suggestion only, and will vary depending upon the constitution of the patient, her medical history, and TCM diagnosis. This data is taken from Liang (2003) 11 and personal practice. A more detailed description of IVF acupuncture treatment is presented in a previous publication1.

Conclusions

The use of acupuncture as an adjunctive therapy for women undergoing IVF is increasing. Acupuncture provides therapeutic benefit by reducing the psychological symptoms and medical procedure side effects, as well as often increasing the possibility of pregnancy. There have been six published randomized controlled trails examining the impact of acupuncture upon IVF outcome. Three of these trails showed that women receiving acupuncture had significantly greater pregnancy outcomes compared to non-treated controls. These trials had significant methodological limitations, including poor acupuncture protocols. The development of acupuncture treatment protocols for women undergoing IVF must be undertaken with careful consideration of the medications, procedures and side effects associated with different parts of the IVF cycle. The use of acupuncture to improve the outcome and quality of life of IVF patients is an example of the significant value and role of acupuncture within an integrated medicinal context. OM