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complementary and alternative medicine, evidence based medicine, infertility, Lasso of truth

Acupuncture does not improve pregnancy rates in IVF

Acupuncture has become, for many women, an accepted part of their infertility journey. Several studies, including a meta-analysis of 24 studies published in the journal Fertility Sterility in 2012, indicated higher pregnancy rates among women who had undergone acupuncture as part of their treatment protocol compared with women who had no acupuncture or a sham procedure. Any improvement in outcomes is welcome considering the emotional and financial drain of each cycle.

However, there are significant methodological problems many acupuncture studies, several of which were included in that 2012 meta-analysis. Unfortunately publication, even peer-reviewed publication, does not guarantee quality. An old professor of mine used to say the only reason someone didn’t get a study published was they didn’t have enough stamps. The equivalent today would be the only reason someone doesn’t get published was they didn’t hit send enough times. I’m all for open-access, the sheer number of bad studies that get out into the ether is frightening.

So, with that in mind two different groups have revisited acupuncture and assisted reproduction discarding studies that should never have been included (never mind published) in the first place. One is a Cochrane review (July 2013) that found 20 studies of sufficient quality to analyze and the other published in Fertility Sterility (June 2013) that felt 16 studies were worth reviewing. Two groups of investigators independently reviewing the literature and publishing in different sources reached the same conclusion, “There is no evidence that acupuncture improves live birth or pregnancy rates in assisted conception.”

What if acupuncture makes someone feel better, thereby reducing stress? Wouldn’t that be of value? Well, some studies do suggest (small studies, I might add) that women undergoing IVF who are getting acupuncture report score lower anxiety levels, however, how much that is a physiologic reaction to acupuncture and how much is the false belief that acupuncture is going to help is unknown. The small studies that look at acupuncture and stress reduction didn’t ask the participants if they believed the acupuncture would help them conceive or if they were told by their doctor acupuncture would help. I wonder what the effect of acupuncture would be on anxiety associated with assisted reproduction if participants were told the medical evidence suggests that acupuncture is no more effective than placebo and does not improve pregnancy rates?

I understand the stress of infertility therapies on a personal level and I understand the desperation to do everything. When acupuncture was offered to me in 2002 when I was pursuing assisted reproduction I declined. I read the few studies that were available at the time and they did not seem robust at all.

Acupuncture doesn’t seem to help with the desired outcome of pregnancy, so imbuing women with a false sense of hope seems the wrong way to go about reducing stress. There are wonderful mind-body techniques to lower anxiety and so infertility providers are better off steering patients to more evidence based (and less expensive) practices than jumping on the we-offer-acupuncture-so-come-to-our-clinic bandwagon.

Current medical evidence suggests acupuncture does not improve pregnancy rates.  Offering it outside of a well-designed, prospective, large clinical trial seems unjustified and women seeking infertility therapy could probably use the money and hope they were planning to spend on acupuncture elsewhere.

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Discussion

16 thoughts on “Acupuncture does not improve pregnancy rates in IVF

  1. How do you explain women who have amenorhea or irregular menses- and the only thing that worked was acupuncture/Chinese herbs? It’s not placebo- they didn’t have high hopes for it b/c “nothing” was working in the Western world where everyone is under the belief that’s the only thing that works. Where Western medicine fails, often natural medicine offers a huge array of offerings. There is ZERO harm in at least trying it. These “studies” blow chunks. They don’t relay how long, how often, herbal remedies used etc. It takes about 3-9 months of persistent treatments of acu and herbs for serious infertility regimes. You- as a healer- should never advise the masses to never try something that is 1. harmless 2.actually can and could help (placebo or not- seriously there are MD’s out there still “concerned” about the threats of placebo? Surely you have read about the countless attributions about how placebo came about- namely from regulatory used BY MD’s with pharmaceuticals? One of the biggest shams lies right there with MD’s and drug companies—-read about the massive GlaxoSmithKline exec who quit over the resolution that nearly half of their products efficacy is a placebo? Their massive side effects however- are not) I can respect you not wishing to participate in holistic health care- but when millions of people- children, pets, and women over thousands of years have been helped by it- please stop with the absolute opinions and blasts like this. You are doing no one any favors. You are harming the potentials of health care. Do we understand how or why plants or acupuncture or homeopathy work? No. Does this invalidate it? In your world, yes. B/c you need studies that are “robust” according to you. This simply means a lot of money and time- neither of which the FDA or pharmaceuticals will ever desire to put aside for holistic health care- what they deem is a threat and competition. There is very little money in a plant curing cancer, after all. But this is where limitations prevent progression. This is also where hope dies for patients and the masses. This is the danger in science and health care. Please stop with your resolutes on something so vast and complicated.

    Posted by sl | October 8, 2013, 10:32 am
    • Thank you for posting, although I’m wondering if you read the post or are just looking for a platform. The post is most definitely not about amenorrhea or irregular menses, it is clearly about assisted reproductive technologies and the pregnancy rate when acupuncture is used. Saying acupuncture doesn’t work for IVF is not a comment on the efficacy or lack thereof for any other medical condition.

      As a physician it is my duty to support therapies that work. If acupuncture for IVF were effective it would stand up to the scrutiny of the scientific method. It does not. I’m not sure how insisting on the science in medicine actually harms the “potentials [sic] of health care” as you claim. Understanding how a therapy works is important, but if the therapy does not hold up to the scientific method then it simply isn’t valid.

      The harm in false-claims is the false hope and the expense of a placebo. It is also unethical. Charging (often a lot of money) for a placebo under the guise of real therapy is exploitation. If the idea of having treatments that don’t work appeals to you, then that is your choice. However, many people get acupuncture for IVF in the belief that it will help and most actually want to know how well their treatments work.

      If you read my bio before spouting off insults you would know that I am not for or against allopathic or alternative medicine, I am for evidence based medicine. If there are high quality studied supporting the efficacy and safety of a treatment, I am all for it.

      By the way, holistic care is not acupuncture or homeopathy.

      Posted by Dr. Jen Gunter | October 8, 2013, 6:41 pm
      • Holistic health care absolutely is acupuncture and/or homeopathy. http://www.webmd.com/balance/guide/what-is-holistic-medicine . I would love to know why you think it is otherwise? (I’m not trying to be sassy here)

        Many infertility issues stem from irregular menses and at times even amenorhea. One needs to have a healthy cycle for healthy fertility rates- acupuncture can and does regulate the cycle- not just the active bleeding part but ovulation and the building of the new lining as well. Can it stand up to your medical scientific scrutiny? Depends on the study you read actually. There are plenty that support it too. The proof is in the women getting preggers with it. Sometimes with and sometimes w/o the additional aids of a Western fertility clinic too. Perhaps science hasn’t caught up with how to prove it- but the results are there. As I mentioned before- a lot of these “studies” performed are a crock.
        If you are for evidence based medicine- then don’t the result provide some sort of evidence? Once upon a time “science” believed the smallest particle in the universe was an atom. We now know differently b/c science is still catching up. Once upon a time “science” insisted the sun revolved around the Earth. At what point can you just understand that to not understand doesn’t invalidate something? Truth, is separate from testing and tools and understanding.

        I suggested that steering clients away from natural medicine b/c “this and that” study says it aint working (we still haven’t covered how effectively these studies took place) is potentially harmful b/c encouraging people to remain in “science” based medicine often leads to the intake of drugs. We can no longer get fresh fish in the US that doesn’t contain high levels of estrogen. Why? B/c half of the females who live here are on the pill. There are alternatives. If acupuncture can and does help with PMS, acne, irregular menses etc, we are sparing a lot of cost (yes, cost- but this is another dialog) and side effects. Not just on her- (studies are also coming forth about how long term use of the pill can increase infertility too) her liver, her kidneys etc but the environment- holistic health care…..it considers the whole. Always.

        I don’t think we can argue placebo. I will agree there are not enough tests that are worthy or valid enough to claim acu or herbs can or can’t do “x,y and z” in the ways we want to “see” it. Placebo- maybe. But 1. How does one explain the immediate positive effects on children? Even before speaking age? The rapid positive effects on pets and animals? Or the positive effects on the military who are pretty certain no acupuncture can help ease the PTSD of war b/c nothing else has helped? 2. Western med is loaded with placebo relationships. So to suggest that someone rely on Western b/c natural is placebo is simply unfair and twisted.
        Thank you.

        Posted by sl | October 8, 2013, 7:18 pm
      • Holistic care is looking at the whole person, or “relating to or concerned with complete systems rather than with individual parts.” The term holistic has been co-opted by alternative medicine practitioners. Acupuncture does not address the whole person, it addresses chi. Could acupuncture be part of holistic care? Yes, but any treatment could be.

        Posted by Dr. Jen Gunter | October 10, 2013, 1:40 pm
  2. Is there evidence that acupuncture provides stress-relief, outside of the sense that it is providing a conception advantage? It certainly did for me — I went before and during an IVF cycle, as well as during the subsequent pregnancy. (My pre-conception goal was anxiety relief, not improved conception odds; during pregnancy I did find it provided short-term improvement in various annoying symptoms (nausea, rhinitis), though usually only for a few days. Better than nothing!) The community acupuncture model made it the cheapest form of mind-body therapy available to me, though you are certainly right that it would have been very expensive to get treatments at the actual fertility clinic.

    Posted by bionicbrooklynite | October 8, 2013, 5:17 pm
  3. Great blog post. I will point out though that the Cochrane Review does say “More research is needed before recommendations can be made, including studies in which some controls receive placebo needling and others receive no intervention” so while is it looking to point in the direction of acupuncture not having an pregnancy rates, I think it is still a bit too early to make conclusions.

    Also I am interested in that you have a negative view point of placebo. I’m a med student and we just had our neuro block, where the pain physician really stressed that placebo can be very powerful, and can be just as effective as pharmacologically active drugs. I can appreciate though that you are speaking out against companies ripping people off.

    It’s an interesting situation when the evidence is saying no, but so many individuals are saying yes. While it’s the best thing we’ve got, I don’t think evidence based medicine offers definite conclusions. Perhaps acupuncture offers some benefit that has yet to be measured, or is only benefiting a certain population. In the end, if I were trying to conceive and Cochrane told me acupuncture didn’t help, but a few of my friends told me how it helped them, I would probably give it a go (even if I were paying for placebo.)

    Posted by thebeautyofscrutiny | October 8, 2013, 9:04 pm
    • When the summary of the highest quality 16-20 studies don’t indicate a positive outcome it is hard to recommend a therapy outside of a clinical trial. It is possible, as with many CAM therapies, that the trials were all just not well designed/properly placebo controlled/under powered to show effect. However, how many more articles are needed to say this isn’t working? It was really eye opening to read some of the studies that were included in the original meta analysis in 2012. They were atrocious

      The problem with placebo is several fold. Is is ok to offer surgery if the placebo response rate is 27% even though that means the risk of general anesthesia? What about a medication with serious side effects? The medical value of the placebo effect has to be weighed against the risk. How much risks should one assume for a placebo response rate? Also, should insurer or governments pay for a treatment that is no better than placebo? Finally, there are ethical concerns. It is generally not considered ethical to prescribe a medication or do a treatment for placebo effect without informing the patient. There is fantastic study published by a group from the VA in Dallas about placebo and arthroscopic surgery with sham surgery. Is was in the NEJM. I think it should be required reading for every doctor and medical student. Sadly, many doctors still do this kind of surgery even though it’s no better than placebo.

      Placebo response in pain medicine is very high. There is a well done study looking at known placebo for IBS. The patients were told that there were getting a sugar pill that contained no active ingredients, also called a placebo, but studies indicate that placebos can help. This was compared with just a standard script about managing IBS symptoms. The response in the IBS patients was over 60% with known placebo. The placebo response is known to release natural opioids (it can be blunted with Narcan), and so placebo for pain can’t be compared with placebo for IVF because if acupuncture did work for IVF it would unlikely be via the opioid response system.

      Placebo responses are suspected many times. If I start someone on an adjunct medication for pain and they feel better in 3 days, that is placebo response as these medications are take longer than that to work. Or a patient might tell me the medication has sured or well-treated their pain at a dose so low it is biologically implausible. Again likely a placebo effect. However, that is very different that deceiving someone by telling them a treatment works when there is no medical evidence to say it does not.

      To find subpopulations that might benefit would require far more robust studies than exist. There are enough people doing acupuncture for IVF that they could certainly do that if they were motivated.

      The big issue is preying on the desperate, whether you’re desperate to get pregnant or desperate to make your pain go away. Telling someone that acupuncture will help them conceive is not supported by the current body of literature. It’s just as bad to do knee surgery when it’s not likely to be helpful or doing epidurals for back pain when the studies are very disappointing.

      Posted by Dr. Jen Gunter | October 10, 2013, 1:37 pm
      • For any treatment that is prescribed to a patient, it is a question of cost vs benefit. And while you are right in that if the benefit of placebo has to be weighed against numerous side effects, the dangers of general anaesthesia, or an extremely expensive cost, then I agree that those risks outweigh the benefits. To my knowledge, acupuncture has no significant side effects and is inexpensive.

        I agree whole-heartedly that it is ethically wrong to tell a women trying to conceive that acupuncture has been proven to increase fertility by a certain %. If the science isn’t there, then providers of acupuncture and IVF shouldn’t use scientific claims to sell their practice. If a provider however is completely upfront with their patient, acknowledging that the scientific evidence has shown that there is no statistical significance in improving pregnancy rates, though some individuals (such as some of the people who have commented on this post) swear that it provides some sort of stress relief that benefitted them throughout the process of IVF, then I think that’s honest and that is enough information for a patient to make their own decision.

        I was reading that cochrane review, and this is what was said: “The quality of individual studies was generally low, with over 75% failing to describe an adequate method of allocation concealment” so while not discounting the research and conclusions obtained, the authors acknowledge some flaws. Also I was interested in that the rates of clinical pregnancy was a tiny bit higher in the treatment groups. Quite far from reaching statistical significance but it reminds me that you need a huge sample to report a tiny difference for it to be noted as significant. Whether such a tiny difference would be worthwhile comes down to a cost vs benefit scenario again.

        Thank you for the information about placebo I found it very insightful- it makes sense that it works on the opioid system because it’s well-documented effect in pain medicine.

        This is a quote by V.S. Ramachandran that I read in “The Brain that Changes Itself.”
        “Imagine I were to present a pig to a skeptical scientist, insisting that it could speak English, then waved my hand, and the pig spoke English. Would it really make sense for the skeptic to argue, ‘But that is just one pig, Ramachandran. Show me another, and I might believe you!’ ”
        Skepticism in science is both a blessing and a curse as it protects us from our own biases, but it may mean we dismiss the those fascinating, individual cases where something did actually happen!

        Posted by thebeautyofscrutiny | October 12, 2013, 5:09 pm
  4. Very entertaining, SL. Remember there are proven treatments and unproven. Alternative medicines that have been proven become known simply as medicine! BTW, science-based doctors, if they are any good, take a ‘holistic’ approach to their patients in that they treat the whole person, but not necessarily by charging them for as many forms of woo as they will tolerate.

    Posted by lancelotgobbo | October 9, 2013, 6:27 am
  5. “Holistic care is looking at the whole person, or “relating to or concerned with complete systems rather than with individual parts.” The term holistic has been co-opted by alternative medicine practitioners. Acupuncture does not address the whole person, it addresses chi. Could acupuncture be part of holistic care? Yes, but any treatment could be.”

    I respect you are very smart and know what you know solidly. “Qi” or “chi” is not one of them. Nor is acupuncture or homeopathy as clearly demonstrated by what you said. Theory 101 in learning/studying/applying acupuncture is about qi- and qi is in everything. Blood follows qi and qi makes blood. It is the whole. There are also several forms of qi- wie qi protects a persons immunity- gu qi is the energy from food etc.

    I just simply advise Doctors stop insisting they have a handle on entire medicinal modalities they don’t know anything about. Respect professions and stop making blanket statements- esp when they don’t know.

    Anyone can pick several studies pro or con about practically any procedure. From massage to drugs to herbs. The danger lies in medical professionals spewing opinions and conclusions when they have never tried it themselves or studied it. It lacks professional respect and creates barriers and limits potentials for patients.

    You read some studies- that is all. From their I respectfully have to say you don’t know what you are talking about on this matter.

    Posted by sl | October 11, 2013, 8:41 am
    • ‘Qi’ is a hypothetical construct, a pre-scientific idea. It has as much validity today as the four humours. If my doctor started telling me that I had an excess of black bile, or that I needed to be bled over a bowl because my blood was out of balance then I’d wonder if he’d suffered a head injury.

      Same goes for ‘Qi’, the various kinds of pulse activity (slippery pulses? yeah right), and meridians. Utter tripe that belongs in the. Middle Ages.

      Posted by neverdefiled | October 16, 2013, 4:38 am
  6. Hi Dr. Gunter,

    Back in January you said you would post about the flaws of HSV viral samples and I was hoping you could still do that. Mine came back positive but I want to know what to ask for in the future. Were you still going to post about that?

    Thanks so much for your insight! I’m a new reader and this is my new favorite blog.

    Posted by Nick | October 19, 2013, 1:27 am
    • Aww bless your heart, you actually think that posting a flawed, worthless “study” from a biased source is a comeback?

      Acupuncture has been proven time and again to be completely ineffective.

      Sticking needles into random points has the same effect as using so-called “meridians”. Blinding subjects and twirling cocktail sticks against their skin has the same effect as acupuncture. Double-blinded studies where the acupuncturists don’t realise they are using specially-designed needles that don’t actually puncture the skin, on subjects who believe that their skin is being punctured, has the same effect as acupuncture.

      It’s bunk, bollocks, bullshit, bloody ridiculous nonsense that’s beloved by the worried-well.

      Science > nonsense

      Posted by neverdefiled | October 25, 2013, 2:13 am
      • It is not from a biased source. It’s reported from a biased source, but the study had nothing to do with anything “pro acupuncture”.
        Thank you for being so reasonable. I thought for a moment there that WHO, NIH, Dr. Christine Northrup, Dr. Andrew Weil, Candice Pert, and a boat load of other scientists, doctors and organizations were on to something. Not to mention the countless accounts, and thousands of years. But you got it all sorted! Actually, this dialog is futile. There becomes a point where we all agree to disagree. My point of this entirety was for medical professionals to exercise caution on making blanket statements- esp when they really actually don’t know the topic they are opining about aside from a handful of studies that are incomplete and questionable on their studying. There are a TON of studies debunking and a TON showing the efficacy. There are a TON of positive result testimonials and a TON of “it did nothing”.
        When there are positive outcomes, the common corner MD’s then take when it works is “Placebo! It’s Placebo by golly!” Well, none of them address the children or animals benefiting. Dr.Gunther has been quite quiet on a few of these points, not just this one. There are also virtually ZERO side effects. “Well, I heard of a guy who knew a guy who’s lungs got punctured”. Yep. About twice a year something drastic happens- usually by someone who is not an acu- but trained in the accelerated weekend classes who got certified. Point being- it can’t hurt and there is too much positive to simply suggest everyone write it off- esp as an MD. People respect and hold high regards to MD’s. They are the word of God for many- so they must use and choose their accusations and surmises carefully and respectfully.

        Posted by sl | October 25, 2013, 7:19 am
      • Well, you lost me at Dr. Christine Northrup as she is a woo monger extraordinaire

        Posted by Dr. Jen Gunter | October 26, 2013, 1:01 pm

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