To the Editor:
We read with great interest the recent article by Moy, et al. (1)
After its mysterious origination over 2500 years ago, acupuncture had spread rapidly through Asia, and been applied in Europe since the early seventeenth century. (2) Based on controlled clinical trials, extensive data about the efficacy of acupuncture have been gathered over the past three decades, providing valuable insight into the experience-based practice. We have the following concerns about the present study:
1. One difficulty in evaluating acupuncture in practice is that the therapeutic effect depends greatly on the proficiency of the acupuncturist — on his ability and skill in selecting and locating the acupuncture points and in manipulating the needles. This may partly explain the disparities or inconsistencies in the results reported by different authors, even when their studies were carried out on equally sound methodological bases (2).
2. There are as many causes for infertility as infertile cases. Although the authors described reasons for infertility, not every case in the same group had the same severity, which, along with the 39 cases with unexplained causes, might constitute high heterogeneity in group allocation. When using the methods of traditional Chinese medicine (TCM), the diagnosis and treatment should also be based on TCM theories, which emphasize the interaction and regulation of systems and organs in human body. However, the guidance of TCM theories is missing in the present study.
3. The authors chose a dozen acupoints and left the needles for 25 minutes without stimulation. Therefore, it is not clear whether the efficacy of the acupuncture, or lack thereof, was due to the synergistic effect of these acupoints, or to their interference with each other. The authors left the needles for only 25 minutes,
and removed them afterwards. Might it be beneficial to leave the needles in with intermittent stimulation and longer time?
Ideally, the acupoints should be personalized according to the symptom and condition of each patient. Randomized controlled trials are only valuable under strict control of heterogeneity.
Zhongjie Shi, M.D., Ph.D.
Department of Obstetrics and Gynaecology
Third Affiliated Hospital of Sun Yat-sen University
Heilongjiang Academy of Traditional Chinese Medicine
1. Moy I, Milad MP, Barnes R, Confino E, Kazer RR, Zhang X. Randomized controlled trial: effects of acupuncture on pregnancy rates in women undergoing in vitro fertilization. Fertil Steril 2011;95:583-7.
2. World Health Organization. Acupuncture: review and analysis of reports on controlled clinical trials. Available at
http://apps.who.int/medicinedocs/pdf/s4926e/s4926e.pdf. Accessed on February 8, 2011.
Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2011.03.039
The Authors Respond:
We would like to thank Dr. Shi and colleagues for their interest in our paper. We agree that the proficiency of the acupuncturist is key in any study investigating the effects of acupuncture on a particular medical condition. We were happy to have collaborated with two highly trained, hospital-employed, licensed acupuncturists in our study. Both of our acupuncturists had over a decade of practice prior to joining our study. In fact, our lead acupuncturist completed advanced studies at the Guangzhou University of Traditional Chinese Medicine in China prior to her employment at Northwestern.
Regarding our demographic information, we considered all factors that could have potentially been different between the “sham” and “true” arms and did not find any statistical difference. In our discussion section, we acknowledged that the fixed protocol used in our study may have reduced the likelihood that the treatment was effective on an individual basis. We also acknowledged that our study was not consistent with traditional Chinese medicine (TCM) principle, and we recommended future studies of adequate power and sample size employing TCM.
In regard to the length of time in needle placement, our 25 minute allocation was adapted from the Paulus et al. study. During the planning of our study, we realized that we would be unable to adhere to the principles of TCM and consulted with our acupuncturists to develop the best protocol within the constraints of a controlled trial. Near the end of our study, recruitment of patients became increasingly difficult due to the fact that many of our patients were seeking acupuncture and TCM prior to their initial clinic visit. With the growing interest in the field, future studies that explore more comprehensive TCM treatments on infertility will be met with great interest and will help shed more light on the topic.
Irene Moy, M.D.
Magdy P Milad, M.D.
Division of Reproductive Endocrinology and Infertility
Northwestern Feinberg School of Medicine
Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2011.03.038