To the Editor:
Zheng et al (1) claim in their meta-analysis that there is no significant difference between acupuncture and placebo when it comes to live birth rates among women undergoing in vitro fertilization because the Streitberger procedure where needles do not enter the skin, which was used as placebo acupuncture, appears to be more effective than acupuncture itself. This might be interpreted as a recommendation to choose the Streitberger procedure over acupuncture as the active treatment. The authors seem to agree, saying “…the harmful reaction produced by real acupuncture can be avoided by this noninvasive stimulation…”.
However, we do not share this implied recommendation, since nothing in this article distinguishes the direct effect of acupuncture from the effect of the broad psychological/social/cultural environment in which it is performed. The authors use the term ‘acupuncture’ without making this distinction. Is acupuncture something that could be performed by a robot on robot-like participants with no deeper meaning involved? Acupuncture probably means much more than that to the authors, as it does to us.
The authors claim that the Streitberger procedure is not a valid placebo, but using comparable reasoning, it may be that acupuncture can be equally active only through a placebo effect. Assuming that everything that works is not itself a placebo leaves acupuncture not provable, therefore not proven if not through rational means. This reasoning suggests that all treatments may be placebo. Acupuncture has many characteristics that could lead to a placebo effect such as invasion of the integrity of the skin, having an aura of ancient wisdom as did bloodletting for 1600 years in the West, being exotic in the West and homemade in China, displaying strange-looking images of meridians through which the ephemeral life energy Qi might flow, etc. We only wish to say that this is a very placebo-prone procedure about which the authors strive to point out that there is no positive proof when compared with a satisfactory placebo.
We think it is worth spending research resources investigating the exact nature of Qi. We understand the deep importance of Qi in Chinese culture. However, to bring it by way of metal needles in a materialistic manner truly denigrates it, as is mainly done nowadays in the West. In the end, choosing empathy and inner human strength, a part of sub-conceptual processing, which is to us the real Qi, instead of placebo-prone cold needles is a matter of self-respect.
The Streitberger procedure proves to us that the power of placebo, in a broad sense, extends to the domain of fertility. More research is needed. Also, we fear that the idea of acupuncture, implying something outside oneself, stands in the way of inner strength, which is something inside oneself. The feeling of helplessness is one of the most important causes of functional disorders. This might eventually even influence fertility in a negative way. This, too, should be an object of research.
Jean-Luc Mommaerts, M.D., M.Sc.
Dirk Devroey, M.D., Ph.D.
Department Of General Practice
Faculty of Medicine
Free University of Brussels
1. Zheng CH, Huang GY, Zhang MM, Wang W. Effects of acupuncture on pregnancy rates in women undergoing in vitro fertilization: a systematic review and meta-analysis. Fertil Steril. 2012 Jan 11. [Epub ahead of print]
The authors declined to reply to this letter.
Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2011.12.053