Acupuncture and IVF trial

12 05 2009

I have some real concerns about the implications and conclusions drawn from the study of Domar et al. (1).

This study explores the effects of one protocol on IVF treatment. The study was indeed attempting to make sure that this was as close to the same protocol as used in the 2002 study. So really all they were doing were checking the efficacy of those points in increasing success rate with IVF. The points were picked to relax the subjects and were successful as reported by the subjects. The points were also to increase blood flow to the uterus, which is because two points affect circulation.

I suspect that because the original study by Paulus (2) had shown increased success rates with that acupuncture protocol, several research teams decided to use the same point protocol or slight variations of it. But as an acupuncturist of 32 years with quite extensive experience in treatment of infertility for the last 6 years (over 500 women), I would design a treatment differently. The most common pattern I have seen would not be addressed by this protocol. But what is even more important is that traditionally acupuncture calls for an individualized assessment and treatment based on that assessment. It is a very low level acupuncture that uses the same treatment for all patients with the same symptoms or as in this case, the same situation (IVF) without regard to their individual issues. I feel it is essential that we have more outcome studies done, which really would allow acupuncture to be examined in the way it is practiced by skilled practitioners in clinic situations.

What is of a lot more concern is that the conclusion was attempting to generalize from a trial of one protocol to all of acupuncture. Would we accept the conclusion that if one drug could not treat the headaches of a significant number of participants in a trial, that drug treatment for headaches is not advised? It is a very similar situation to treat every woman the same regardless of their acupuncture diagnosis with a protocol that has not been compared to other protocols and draw the conclusion that perhaps acupuncture is not a treatment that works in this situation at all.

The good that comes out from this study is that this particular protocol is not “The Gold Standard” acupuncture treatment for using with IVF. On the other hand this study comes to the conclusion that acupuncture might not be useful at all, with little evidence to that. It is indeed a disservice to the scientific study of acupuncture, which is very tricky to design, to make these kinds of generalizations. This is a widespread issue with the trials of acupuncture as a one-size-fits-all protocol only gives information on that protocol not on the possibility of success with acupuncture. This kind of study design works better for drug trials.

Zoe Brenner, L.Ac., Dipl.Ac., Dipl.C.H., FNAAOM
North Bethesda, MD

References
1. Domar AD, Meshay I, Kelliher J, Alper M, Powers RD. The impact of acupuncture on in vitro fertilization outcome. Fertil Steril 2009; 91:724-6.

2. Paulus WE, Zhang M, Strehler E, El-Danasouri I, Sterzik K. Influence of acupuncture on the pregnancy rate in patients who undergo assisted reproduction therapy. Fertil Steril 2002;77:721–4.

Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2009.05.032

The Authors Respond:

Many thanks to Ms. Brenner for her timely comments about our study on the potential efficacy of acupuncture in increasing pregnancy rates in IVF patients. 

When we designed the study, we did not set out to investigate how different acupuncture protocols might influence pregnancy rates. We clearly stated our purpose in the abstract and in the introduction: “the purpose of the study was to replicate the original Paulus study and to assess the potential contribution of a placebo effect” (1).  The Paulus study (2) has attracted a huge amount of media attention and infertility patients have been seeking out acupuncture treatment in increasing numbers. According to normal scientific principles, an attempt to replicate any study by including an appropriate placebo group is warranted any time that patient care can be influenced by a single study.

I do not disagree that according to the principles of traditional Chinese medicine, patients need to be evaluated on an individual basis and their treatment must reflect the results of that evaluation. In the mind/body center that I direct, where we have approximately 4000 acupuncture patient visits per year, infertility patients who seek out acupuncture do receive individualized treatment. However, patients who come in for pre- and post-embryo transfer acupuncture receive treatment modeled after the Paulus protocol since that is the only protocol which had research to support it.  

I agree that we need more outcome research on the relationship between acupuncture and infertility and in fact have tried unsuccessfully to obtain funding to perform exactly the study Ms. Brenner describes, where each patient receives an individualized acupuncture approach.

In terms of the criticism of the conclusions drawn from this study, if  a study was performed on the impact of a certain medication on headaches and no benefit was observed, the conclusion in fact would appropriately be that the medication in question was not of value. In our conclusion we did not state that acupuncture was useless in infertility.  We simply recommended that more research was needed to determine the role of acupuncture for IVF patients.

Alice D. Domar, Ph.D
Domar Center for Mind/Body Health
Boston IVF

Department of Obstetrics, Gynecology, and Reproductive Biology
Harvard Medical School
Boston, MA

References
1. Domar AD, Meshay I, Kelliher J, Alper M, Powers RD. The impact of acupuncture on in vitro fertilization outcome. Fertil Steril 2009; 91: page 723.

2. Paulus WE, Zhang M, Strehler E, El-Danasouri I, Sterzik K. Influence of acupuncture on the pregnancy rate in patients who undergo assisted reproduction therapy. Fertil Steril 2002; 77: 721-4.

Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2009.05.031

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One response

14 05 2009
Zoe Brenner, L.Ac.

I appreciate the responses to my letter. And I would like to add an idea to the question of to why the results of the 2 studies can be different. With relatively small numbers of subjects, a one-size-fits-all acupuncture protocol can be skewed quite a bit by who the subjects are. If the majority of subjects do not have an imbalance that is addressed by the points chosen, then the results will not be as good as a study in which they have the same kind of imbalance as the protocol treats. There is considerable discussion about the protocol chosen amongst acupuncturist as some think that some of the points are contraindicated for post-transfer. There are women that I have encountered, that this treatment would imbalance them more. If the majority of subjects were in that category, the results would not be good. It would help to at least make some general categories of imbalances and thus the protocols could be a little more specific.
As I stated in the first letter, I think that these trials of this particular acupuncture protocol are just trials of this protocol as applied generally to women undergoing IVF treatment. To me this means that we have to continue to work on how to best design studies to test the efficacy of acupuncture and I think it is difficult.

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