ORIGINAL RESEARCH

IN VITRO FERTILIZATION AND ACUPUNCTURE:CLINICAL EFFICACY AND MECHANISTIC BASISBelinda J. Anderson, PhD, LAc; Fiorina Haimovici, MD; Flizabeth S. Ginsburg, MD; Danny J. Schust, MD; Peter M. Wayne, PhD

Objective • To provide an overview of the use of acupunctureas an adjunct therapy for in vitro fertilization (IVF), includingan evidence-based evaluation of its efficacy and safety and anexamination of possible mechanisms of action.Design • Literature review using PubMed, the Science CitationIndex®, The Cochrane Library (Database of SystematicReviews and Central Register of Controlled Trials), the NewEngland School of Acupuncture library databases, and a cross-referencing of published data, personal libraries, and Chinesemedicine textbooks.

Results • Limited but supportive evidence from clinical trialsand case series suggests that acupuncture may improve the suc-cess rate of IVF and the quality of life of patients undergoing IVFand that it is a safe adjunct therapy. However, this conclusion

should be interpreted with caution because most studiesreviewed had design limitations, and the acupuncture interven-tions employed often were not consistent with traditionalChinese medical principles. The reviewed literature suggests 4possible mechanisms by which acupuncture could improve theoutcome of IVF: modulating neuroendocrinological factors;increasing blood flow to the uterus and ovaries; modulatingcytokines; and reducing stress, anxiety, and depression.Conclusions • More high-quality randomized, controlled trialsincorporating placebo acupuncture controls, authentic acupunc-ture interventions, and a range of outcome measures representa-tive of both clinical outcomes and putative mechanistic processesare required to better assess the efficacy of acupuncture as anadjunct for IVF. {Altern Ther Health Med. 2007;13(3):38-48.)

Belinda J. Anderson, PhD, LAC, is the academic dean at PacificCollege of Oriental Medicine, New York. Fiorina Haimovici,MD, is the director of Education in Medical Psychiatry atFaulkner Hospital and an instructor in Psychiatry at Brighamand Women's and Faulkner Hospitals, Harvard MedicalSchool, Boston, Mass. Elizabeth S. Ginsburg, MD, is medicaldirector of the In Vitro Fertilization Program at Brigham andWomen's Hospital, Harvard Medical School. Danny J.Scbust, MD, is an associate professor of Obstetrics,Gynecology and Women's Health and division head.Reproductive Endocrinology and Infertility at ColumbiaSchool of Medicine, University of Missouri, Columbia, Mo.Peter M. Wayne, PhD, is a director of research in theResearcb Department at tbe New England School ofAcupuncture, Watertown, Mass.

Infertility is a significant public health issue with high med-ical and social costs. In the most recent survey by theCenters for Disease Control and Prevention (CDC) investi-gating impaired fecundity and infertility in the UnitedStates, 1.2 million participants (2% of those surveyed) had

an infertility-related medical appointment during the past year.'An additional 13% received infertility services at some point intheir lives, and 7% of married couples in which the woman was ofreproductive age reported they had not used contraception for 12

months but had not conceived. More recent estimates suggestthat 10%-15% of couples experience infertility, with a higherprevalence in women over age 34.

In vitro fertilization (IVF) is the most successful of the infer-tility treatments, and for many people is the last possibility forachieving pregnancy. In 2001 (the most recent year for whichnational data were published), there were 29,344 deliveries fromIVF, which resulted in the birth of 40,687 infants. This represents1% of all US births in that year.'

IVF is the only infertility therapy that can successfullybypass severe pelvic adhesions and male-factor infertility andsimultaneously elucidate causes of infertility for which no othertests exist, such as poor oocyte maturation or failure of embryocleavage. As a result of recent improvements in ovulation induc-tion protocols and adjustments in treatment regimens, 3-6 cyclesof standard IVF can result in more than 65% of patients ultimate-ly delivering a baby.^* The average delivery rate resulting fromIVF per single initiated cycle using fresh, non-donor oocyte, how-ever, was still only 33%. ^ Therefore, the majority of IVF cycles donot result in pregnancy, and there is generally a need for multipleIVF cycles for pregnancy to be achieved.

For many, the cost of IVF is so high that it is difficult toundergo even a single attempt. Estimates of the direct cost to thepatient ofa single cycle of IVF range from $7,000 to $11,000."This figure excludes the cost of medications, which averages over$1,500 per cycle. Only 4 states in the United States mandate full

38 ALTERNATIVE THERAPIES, MAY/JUNE 2007, VOL, 13, NO, 3 In Vitro Fertilization and Acupuncture

insurance coverage for IVF, and 8 mandate partial coverage."Stress, anxiety, and depression are common among patients

undergoing IVF treatment. Potential reasons for this include theinvasive nature of the therapy itself, the knowledge that IVF isoften the last hope for a biological child, and the high cost oftreatment."'" A significant body of literature supports the con-tention that stress, anxiety, and depression contribute to lowerpregnancy rates among women undergoing IVF."'

Due to the relatively low success rate of IVF per cycle, as wellas the high emotional and fmancial costs associated with IVF,many patients have turned to complementary and alternativemedicine (CAM) to enhance the success of IVF treatment.' 'Among CAM treatments, acupuncture is a frequently usedadjunctive therapy. However, whether acupuncture is safe andeffective for IVF has not yet been established. This paper evaluatesthe evidence regarding the eiFicacy and safety of acupuncture forimproving the success rate of IVF. We briefly review the biomed-ical and traditional Chinese medicine (TCM) explanations forinfertility and then critically summarize and evaluate the studiesconducted to date that include data on the efficacy and safety ofacupuncture for improving the success rate of IVF. Finally, wesummarize published research exploring the mechanisms thatmay underlie acupuncture's impact on IVF success and propose 4possible (interrelated) mechanisms for how acupuncture couldimprove IVF success rates.

INFERTILITY FROM A WESTERN BIOMEDICALPERSPECTIVE

A growing body of research has begun to identify a numberof physiological and psychological mechanisms that may underliefemale infertility and explain the limited success of IVF treat-ments. The causes of female infertility can be grouped into 4major categories:'* (1) abnormalities in oocyte production; (2)anatomic abnormalities leading to obstruction of transport of thesperm, oocyte, and/or embryo through the reproductive tract (eg,tubal, uterine, cervical, peritoneal factors); (3) abnormalities inthe implantation process, including early defects in embryo devel-opment, and embryo-endometrial interaction; and (4) numerousother factors that are probably most important in women withunexplained infertility (eg, age, body weight, cigarette smoking,alcohol and caffeine intake, psychological and emotional factors,immunological abnormalities, borderline hormonal imbalances).

The IVF procedure can overcome many of the conditionsthat cause infertility by artificially modifying oocyte production,fertilizing oocytes in vitro, and ensuring delivery of 1 or moreembryos into a hormonally-stimulated endometrium. For thesereasons, combined with the superior success of IVF compared toother assisted reproductive technologies, IVF is widely used forthe treatment of infertility of known and unexplained etiology.

INFERTILITY FROM A TRADITIONAL CHINESE MEDICINEPERSPECTIVE

The application of Chinese medicine to women's health hasbeen practiced for thousands of years, and some of the earliest

written records contain rich and detailed descriptions of gyneco-logical and reproductive disorders and their treatment.'-' Themost commonly practiced form of Chinese medicine today, bothin the West and in China, is TCM."' TCM developed at the turn ofthe last century and represents a systemization of variousChinese medicine practices into a unified medical system thatcould best be integrated with Western medicine.

There are several fundamental theoretical constructs thatform the foundation of the TCM view of the body and its dysfunc-tions. Used together, these underlie a complex system of diagno-sis. In this system, signs and symptoms are analyzed to allow thechoice of one or more TCM patterns that characterize a person'sillness. A treatment strategy is tailored around the TCM patterndiagnoses. Acupuncture, exercise, diet, massage, and the use ofherbs comprise the fundamental TCM treatment modalities.Acupuncture is based on the notion that there are pathways(meridians) within the body where qi (Chi) flows. Along thesemeridians are specific regions (acupuncture points, acupoints)that are used to treat specific conditions. Fundamental to theChinese medicine understanding of the mechanism of acupunc-ture is the idea that stimulation of these points alters the flow ofqi in the meridian system. Scientific studies have shown thatacupuncture points and meridians have unique electrical proper-ties and connective tissue characteristics.'"*

The most common way that the effect of an insertedacupuncture needle is enhanced is through either manual manip-ulation or electrical stimulation. Simple manual insertion ofacupuncture needles with brief manipulation was the most com-mon form of practice until the middle of the 20th century, whenmild electrical stimulation (10-100 Hz) of inserted needles, elec-tro-acupuncture (EA), was developed. The majority of researchinvestigating the efficacy and mechanistic basis of acupuncture(especially when used for pain suppression) has focused on EA,but the most common clinically practiced form of acupuncture inthe United States is manual acupuncture.'* Thus far, there hasbeen only limited investigation into the clinical and mechanisticsimilarities and differences between EA and manual acupuncture.

When considered from a TCM perspective, infertility isalmost always associated with some type of Kidney deficiency,although additional secondary imbalances are often also pre-sent."™ The Kidney in TCM does not refer to the organ and associ-ated functions from a bioniedical perspective (and the "K" iscapitalized). Rather, the TCM concept of Kidney encompasses theorgan and a range of functions and physiological processes, someof which bear no relationship to kidney function in a biomedicalsense. In TCM, the Kidney underlies the fundamental constitu-tion ofa person and in women directly relates to a 7-year cyclecorresponding with developmental changes from birth throughchildhood, puberty, the reproductive years, and old age. Withinthis framework, infertility often reflects an earlier-than-normaldecline of Kidney-related functions that results from either consti-tutional factors (eg, genetic) or lifestyle and dietary issues."Common causes of infertility within the TCM framework are qiimbalances and deficiencies, blood-level imbalances (insufficiency

In Vilro l-erlilizalion and Acupuncture ALTERNATIVE THERAPIES, MAY/|UNE 2007. VOL. 13, NO, 3 39

and blocked circulation), blockages due to the buildup of fluids,and inflammatory processes."" '

Treatment of infertility in TCM begins with the diagnosis ofprimary and secondary patterns, based on the grouping of signsand symptoms assessed using standard examination techniques(eg, pulse and tongue analysis, interview)." According to Liang,the various western medical infertility diagnoses can be viewedwithin the context of the various TCM patterns.^' TCM patterndiagnoses of Kidney yin deflciency. Kidney yang deficiency, blooddeficiency, and qi deficiency include the Western medical diag-noses of anovulation, small or misshapen uterus, poor follicleand/or egg quality, low estradiol, low progesterone, and high fol-licle-stimulating hormone (FSH). TCM pattern diagnoses of qistagnation, blood stasis, and phlegm damp obstruction includethe Western medical diagnoses of blocked fallopian tubes, uterineflbroids, ovarian cysts, endometriosis, adhesions, and stress. TheTCM pattern diagnosis of damp heat includes the Western med-ical diagnoses of infections of the cervix, vagina, pelvis, urinarytract, and fallopian tubes.

Based on the patterns diagnosed, a specific acupuncture pro-tocol (treatment strategy) is developed to address imbalances.The treatment strategy dictates the number and location ofacupuncture points (eg, specific body and ear acupoints), type ofneedle stimulation (eg, manual or electrical), and number and fre-quency of treatments." Though the tailoring of treatment strate-gies to individual primary and secondary diagnostic patterns isstandard in clinical practice and increasingly appreciated inacupuncture research,^^ this approach is not reflected in theresearch on the use of acupuncture in conjunction with IVF that issummarized below.

EVALUATING THE EFFICACY OF ACUPUNCTURE AS ANADJUNCT THERAPY FOR IN VITRO FERTILIZATIONMethods

To review the existing research regarding acupuncture as anadjunct therapy for IVF, we conducted a literature search usingPubMed, the Science Citation Index, the Cochrane Database ofSystematic Reviews, the Cochrane Central Register of ControlledTrials, and the New England School of Acupuncture library data-bases. Additional manual searches of retrieved articles, personallibraries, and TCM textbooks were conducted. Search termsincluded acupuncture or eiectroacupuncture and in vitro fertilizationor IVF or fertility or embryo transfer or ovulation. Only full-lengthstudies (studies reported as abstracts were excluded) that usedeither acupuncture and/or eiectroacupuncture (acupressure wasexcluded) in conjunction with IVF were included in this review.Studies using Chinese herbs in conjunction with acupuncture alsowere included.

ResultsThe table summarizes the 11 studies that resulted from the

literature searches in conjunction with the exclusion and inclu-sion criteria. The table separates the studies according to studyaims and experimental design. The first 4 studies were prospec-

tive randomized controlled trials (RCTs) ' ' specifically designedto address the hypothesis that acupuncture improves the out-come of IVF. The fifth and sixth studies were prospective RCTsprimarily investigating the use of eiectroacupuncture as an alter-native to conventional analgesic methods for oocyte retrieval andalso collected data on IVF outcome."^' The seventh study wasprospective with no randomization,^' and the eighth througheleventh studies were case series"" and narrative descriptions ofcase studies in TCM texts.™"

Randomized, Controlled Trials to Determine Whether AcupunctureImproves In Vitro Fertilization Outcomes

Of the 4 RCTs specifically addressing the hypothesis thatacupuncture could increase the success rate of IVF, 2 had shamacupuncture controls. ''' ^ Of these 4 studies, 3 present evidencesuggesting acupuncture can significantly improve the success ofIVF. The first study, by Paulus et al, included 160 women (averageage 32.5 years) undergoing IVF with or without intracytoplasmicsperm injection (ICSI). ' Two groups were compared (n=80 each).One group received EA 25 minutes before and 25 minutes afterembryo transfer (ET), and the other underwent a standard IVFprocedure without acupuncture. The clinical pregnancy rate inthe non-acupuncture group was 21/80 (26%) compared to 34/80(42.5%) in the EA group.

The Paulus et al study" published in 2002 provided theimpetus for further studies, 3 of which were published in 2006.^"'In a study involving 225 women (average age 34.9 years), Dieterleet al investigated the effect of real (n=116) and sham (n=109)acupuncture on the outcome of IVF with and without ICSl. "Sham acupuncture was undertaken by the use of points that werenot appropriate for fertility-related conditions. Two manualacupuncture treatments were given 30 minutes and 3 days afterET. The group that received real acupuncture compared with thesham group had significantly higher implantation rates (14.2% vs5.9%, respectively), clinical pregnancy rates (33.6% vs 15.6%), bio-chemical pregnancy rates (35.3% vs 16.5%), and ongoing pregnan-cy rates (28.4% vs 13.8%).

Smith et al compared real acupuncture to sham acupunc-ture. ^ The sham intervention involved the use of non-acupunc-ture points and the non-insertive Streitberger needle (the shaft ofthe needle collapses into the needle handle) in women undergo-ing IVF with and without ICSI. All subjects (average age 36 years,randomized into 2 groups) received 3 acupuncture treatments onday 9 of stimulating injections and immediately before and afterET (similar to Paulus et al's methods). Subjects in the realacupuncture group (n=110) as compared with the sham group(n=118) exhibited statistically non-significant trends toward high-er pregnancy rates (31% vs 23%, respectively) and ongoing preg-nancy rates at 18 weeks (28% vs 18%).

In a study of women (average age 37 years) undergoing IVFwith and without ICSI, Westergaard et al compared subjects whohad not received acupuncture (n=87) with those who hadreceived acupuncture immediately before and after ET (ACU 1group, n=95), and with an additional acupuncture treatment 2

40 ALTERNATIVE THERAPIES, MAY/JUNE 2007. VOL. 13. NO. 3 In Vitro Fertilization and Acupuncture

Author, Year

(Reference)

Study

Design

1. Paulus etal, RCT

2002(23)

2. Dieterle etal, RCT

2006(24)

3. Smith etal, RCT

2006(25)

4.Westei^aard RCT

etal, 2006

(26)

aSteiier- RCT

Victorinetal.

1999(27)

6.Stener- RCT

Victorinetal,

2003(28)

TABLE Sutnmary of Studies Evaluating Acupuncture as an Adjunct Therapy for IVF

Study

Population

•160 wonien

•Age 32.5 y; range

28.5-36.5 y

• 225 women

•Avg age 34.9 y;

range 31.3-38.9 y

•128 women

•Avg age 36 y;

range 31.240.9)

• 273 women

•Avg age 37 y;

range 24-45 y

• 150 women

•Avg age 34.4 y;

range 2546 y

•286 women

•Avg age 32.9 y,

range 22-38 y

Intervention

(Sample Size)

•Acu(n=80)

•Control: No Acu

(n=80)

•Acu(n=116)

• Control: placebo

Acu (sham pts)

(n=109)

•Acu(n=UO)

• Control: Placebo

(sham pts,

Streitberger)

(n=118)

• Acu-ltx(n=95)

•Acu-2tx(n=91)

• Control: no Acu

(n=87)

•ACU-HPCB

(n=75)

• Control:

aifentanil+ PCB

(n=75)

•Acu + PCB

(n=141)

• Control:

aifentanil-HPCB

(n=145)

Acupuncture

Treatment

•MA• 25 min before and after ET

• Fixed protocol

•

•MA

• Two txs 30 min and 3 days •

after ET

• Fixed protocol •

••

•MA• 3 txs: Day 9 of stimulating •

injections, before and •

after FT •

•Used Paulus and TCM to •

determine pt selection

(pts not specified)

•MA• 25 min before and after ET •

(Acu-1); plus 2 days post ET

(Acu-2)

•EAandMA <

• One tx, 30 min before and •

until the end of OA •

•Fixed protocol

•EAandMA

• One tx, 30 min before and

until the end of OA

•Fixed protocol

Relevant Outcomes

Measured

Clinical pregnancy— •

presence ofa fetal sac

(by ultrasound) 6 wks •

postET

Uterine artery

pulsatility index

Clinical pregnancy rate •

Biochemical

pregnancy rate

Implantation rate

Ongoing pregnancy rate

Miscarriages

•

Clinical pregnancy rate •

Implantation •

Ongoing pregnancy

Adverse events

Health status

Clinical pregnancy <

Ongoing pregnancy

Pain before/after OA

No. of ICSI cycles

No. of standard

IVF cycles

No. of oocytes retrieved

Fertilization rate

No.ofET

No. of pregnancy, and

miscarriages before

16th wk

Implantation rate

Take-home baby per ET

«Pain before/after OA

' No. of oocytes retrieved

• Fertilization rate

• No. of ET procedures

•No.ofET

• No. of pregnancy, and

miscarriages before

16th wk

Results

Women receiving Acu had a higher clini-

cal pregnancy rate (42.5% vs 26.3%)*

No difterence between the Acu and

no-Acu groups in the uterine artery

pulsatility index

Acu group compared to the placebo group

had significantly higher clinical pregnancy

rate (33.6% vs 15.6%)*. biochemical preg-

nancy rate (35.3% vs 16.5%)*, implanta-

tion rate (14.2% vs 5.9'X))*, and ongoing

pregnancy rate (28.4% v 13.8%)*

No difierence in miscarriages

No significant differences in any outcomes

Clinical pregnancy rate: Acupuncture vs

placebo-34% vs 27%

Acu-1 group compared to control had sig-

nificantly higher clinical and ongoing

pregnancy rates (39% vs 26%) and 36'X)

vs22%)*

Acu-2 group not significantly different

from control

Acu-2 had a higher, but not significantly.

early pregnancy loss compared to Acu-1

and control (33% vs 15% vs 21)

• Acu equal to aifentanil in pain

management

' Acu had significantly higher implantation

rate (27.2% vs 16.3%)*, pregnancy rate

(45.9% vs 28.3%)*, and take-home baby

rate (41% vs 19.4%)* per Err

• Acu greater stress before OA and longer

period of discomfort

• Acu equal to alfentanil in pain

manangement

• No significant differences between

Acu and alfentanil groups in any IVF

outcome measures

• Neuropeptide Y in FF were significantly

higher in the Acu group

In Vitro Fertilization and Acupuncture ALTERNATIVE THERAPIES, MAY/)UNE 2007, VOL. 13, NO. 3 41

Author, Year

(Reference)

7. Balk etal,

2003(31)

8. Emmons

and Patton,

2000(32)

9. Johnson

2006(33)

10. Liang

2003(21)

ll.Lyttleton

2004(20)

Study

Design

CT

Case

series

Case

series

Case

study

Case

study

IBLE Summary o

Study

Population

•10 women

•Avg age 36 y,

range 3141 y

• 6 women

•Avg age 35.8 y;

range 2941 y

• 22 women

•Avg age 36.2 y;

range 31.543.2

•11 women

•Ages 3248 y

• 2 women

•Ages 39 and 40 y

"Studies Evaluating /

Intervention

(Sample Size)

•Acu(n=10)

• Control; No-Acu

group were other

women at the dinic

• Acu (n=6)

•Acu(n=22)

•Control; No acu

group were women

at the clinic during

2003

•Acu and Chinese

herbs (n=10)

•Acu only (n=l)

•Acu and Chinese

herbs (n=2)

Acupuncture as an Adjunct '

Acupuncture

Treatment

•EA

• 2 tx/wk for 4 wk prior to ET

•Fixed protocol

• M A

• 3 4 twice weekly tx on days

l-3,4-6,7-9,and9-lL+txon

day of or prior to egg retrieva

• Eixed protocol+individual

points

• M A

• Introductory and 3 Ril tx

prior to ET, 2 tx 25 min

before and after ET

• M A

• Individual protocol

• M A

• Individual protocol

'herapy for IVF (contii

Relevant Outcomes

Measured

• No. gestational sacs

•Pregnancy and

implantation rates

• No. of on-going

pregnancy

• Neuropeptide

YinFF

•Amount of addi-

tional analgesic

•Uterine artery

pulsatility index

• Endometrial lining

• Eggs retrieved

•Eggs fertilized

• Embryos

transferred

• N o of follicles

retrieved

•Pregnancy rate

•Pregnancy rate past

first trimester

•Fetal heart beat 4

weeks after ET

• Take-home baby

•Take-home baby

lued)

Results

• Acu group reported significant-

ly lower amounts of additional

alfentanil

• 2 hr after OA Acu group

reported significantly less

abdominal pain, other pain,

nausea and stress and were

significantly more calm

• No significant difterences

between Acu and no-Acu group

in any outcome measures

• No pregnancy in non-Acu cycles

• 3 women produced more folli-

cles following Acu tx (11.3 vs

3.9), all 3 women conceived,

but only 1 pregnancy lasted

past the first trimester

• Acu group had greater

pregnancy rate than control

(57.7% vs 45.3%), but not

statistically significant

• Tx resulted in take-home baby

for all subjects

• Tx resulted in take-home baby

for both subjects

Acu=acupuncture; Avg=average; CT=controlled trial; EA=electroacupuncture; ET=embryo transfer; FF=follicular fluid; ICSI=intracytoplasmic sperm injection;IVF=in vitro fertilization; MA=manual acupuncture; OA=oocyte aspiration; PCB=paracervical block; Preg=pregnancy; Pts=points; RCT=randomized controlled trial;Y=years; STAl=State Trait Anxiety Inventory; TCM=traditional Chinese medicine; Tx=treatment'Significant to at least P<.05

days after ET (ACU 2 group, n=91).^'' Clinical and ongoing preg-

nancy rates were significantly higher in the ACU 1 group com-

pared with controls (39% vs 26% and 36% vs 22%, respectively).

The ACU 2 group, compared with the control group, exhibited

statistically non-significant trends toward higher clinical and

ongoing pregnancy rates (36% vs 26%, respectively).

Trials Investigating the Use ofAeupuneture as an Alternative to

Conventional Analgesic Methods for Oocyte Retrieval

Two prospective, randomized studies were aimed primarily

at investigating the efficacy of acupuncture as an alternative to

pharmacological analgesia for ooctye aspiration."'^* These studies

also assessed differences in pregnancy rates between those receiv-

ing acupuncture and those receiving conventional analgesia. Each

of these studies used a single acupuncture treatment (consisting

of EA and manual acupuncture) performed 30 minutes before

oocyte aspiration and lasting until just after aspiration was com-

pleted. The first study showed that women who received acupunc-

ture had significantly higher implantation rates (27.2% vs 16.3%),

pregnancy rates (45.9% vs 28.3%), and take-home baby rates (41%

42 ALTERNATIVE THERAPIES. MAY/jUNE 2007, VOL 13, NO, 3 In Vitro Fertilization and Acupuncture

vs 19.4%) per embryo transfer." The similarly designed subse-quent study^' and others^"" failed to confirm these results.

Prospective Non-randomized Study, Case Series, and NarrativeDescriptions of Case Studies in Traditional Chinese Medicine Texts

In a study by Balk et al, 10 women (average age 36 years)were given EA twice a week for 4 weeks prior to embryo transferand compared with an unknown number of women in the sameclinic who did not receive EA." No significant difference was seenbetween the women who received EA and those who did not inany of the outcome measures.

Emmons and Patton undertook a case series involving 6women (average age 35.8 years) who had previously respondedpoorly to gonadotropin therapy and who were undergoing IVFwith ICSI." These women received twice-weekly manualacupuncture for 3 or 4 weeks. There were no pregnancies in non-acupuncture cycles. Of the 6 women, 3 produced more folliclesafter acupuncture treatment and all 3 conceived; only 1 woman'spregnancy lasted past the first trimester. Johnson undertook acase series of 22 women (average age 36.2 years) who received anintroductory treatment followed by 3 full treatments prior to ETand 2 treatments 25 minutes before and after ET.'' These womenwere compared to other women in the cliriic who had notreceived acupuncture and exhibited statistically non-significanttrends toward higher pregnancy rates (57.7% in the acupuncturegroup vs 45.3% in the no-acupuncture group). A couple of narra-tive case studies involving 13 women who were treated withacupuncture and Chinese herbs reported that all women gavebirth to healthy babies. "' '

Collectively, the studies summarized in the table suggest thefollowing.

Acupuncture may improve the success rate of IVF. Eour of6 RCTs (including 3 of the 4 specifically designed to test improvedpregnancy rates),"" 1 case series,'^ and 13 narrative case stud-ies™ ' suggest that acupuncture may improve IVF outcome.

Acupuncture may improve the quality of life (QOL) ofpatients undergoing IVF. Two RCTs demonstrated that acupunc-ture was equivalent to conventional analgesia for managing painassociated with oocyte aspiration."^' Stener-Victorin et al alsoreported that women receiving acupuncture reported significantlyless abdominal pain, other pain, nausea, and stress 2 hours afteroocyte aspiration compared to women receiving conventionalanalgesia.™ Another RCT reported that women who had receivedacupuncture for pain management associated with oocyte aspira-tion had less postoperative tiredness and confusion when com-pared with women receiving conventional analgesia.^' In 2 of thesestudies, however, patients who had received acupuncture werereported to have experienced greater stress, discomfort, and/orpain."' " Smith et al reported that the most frequently reported sideeffects of the acupuncture treatments were relaxation, feeling calmand peaceful, and feeling energized. ^

Acupuncture may be a safe adjunct therapy for IVFpatients. No adverse events were reported in any of the studiespresented in the table. This coincides with the excellent general

safety profile of acupuncture."''"^Although the studies summarized in the table suggest

acupuncture may improve pregnancy rates and QOL amongpatients undergoing IVF, these results must be considered incon-clusive and interpreted with caution for the following reasons.

The majority of available studies have significant designlimitations. Of the 6 RCTs, only 4 were specifically designed toaddress the hypothesis that acupuncture could increase the successrate of IVF, and only 2 of these included sham acupuncture con-trols. Though case series and non-randomized studies provideadditional support, the absence of randomization and controlgroups in these studies results in great potential for bias. In studiesthat did not include a sham acupuncture control, it is difficult todistinguish the effects of acupuncture needling from placebogenic,non-specific effects associated with treatments."^''" In many studies,details of procedures related to eligibility screening, randomiza-tion, blinding, and statistical analyses were absent. Other reviewsof this literature highlight these and additional limitations of thestudies, especially in relation to the choice of the primary outcomemeasure (pregnancy rate) and a range of issues related to samplesize calculation and statistical analysis of outcome data.''""'

The majority of the acupuncture protocols employed instudies to date do not reflect clinical practice. First, the dosagesof acupuncture eniployed in most of the trials were very low (1-9treatments). In standard clinical practice, acupuncture treatmentprotocols occur over a period of weeks or months, especially forconditions such as infertility, which often are associated withlong-standing deficiencies and imbalances.'^ Second, TCM diag-noses were assessed in only 1 of the trials presented in the tableand even in that study were not used to determine all acupunc-ture treatments." Consequently, in all other studies, treatmentprotocols were not tailored to address TCM-specific imbalancesand symptoms. Rather, the same treatment protocol was given toall subjects regardless of the basis of their infertility from a TCMperspective. This potentially creates a fixed-protocol bias andreduces the likelihood that the treatment will be appropriate andeffective for individual subjects."

Several studies used EA, a form of treatment that is not com-monly used in a clinical setting for the treatment of infertility."'""The choice of acupuncture points was often difficult to under-stand and justify and without a high degree of similarity to sug-gested protocols in Chinese medicine texts.'"' ' Furthermore, somepoints (Sp6 and L14) are contraindicated in pregnancy and maytherefore be unsuitable after ET. This may explain the outcomereported by Westergaard et al ofa greater early pregnancy loss insubjects who were given acupuncture 2 days after ET, as com-pared with those not receiving acupuncture and those only receiv-ing acupuncture immediately before and after ET (33% vs 21% vs15% respectively).'"

Several of the recent study critiques commented on prob-lems associated with the choice of acupuncture points and eartreatments that were used in some of these studies. This toucheson a much larger issue of the authentic use of acupuncture in aconventional medical setting within the confines ofa clinical trial.

In Vitro Fertilization and Acupuncture ALTERNATIVE THERAPIES. MAY/|UNE 2007. VOL 13. NO. 3 43

TCM diagnosis and point selection are complex issues based onan in-depth understanding ofa large body of theoretical informa-tion. Clinical trials need to involve properly trained acupunctur-ists who are knowledgeable in the discipline, preferably withnationally recognized qualifications, certifications, and appropri-ate licenses. This would negate the readers' need to try and under-stand, validate, and justify the acupuncture protocols when themajority of them are not qualified to do so.

Important details of the experimental protocol are notprovided. The qualifications and experience of the acupunctur-ists involved in the design and administration of the treatmentprotocols are poorly described, making it difficult to assess thevalidity of the intervention. Additionally, many other details ofthe experimental protocol, as suggested by the standards forreporting interventions in controlled trials of acupuncture(STRICTA)," were not reported, making the quality of the thesetrials' outcomes difficult to evaluate.

In summary, although methodological problems with theexisting clinical research limit conclusions, there is some evidenceto suggest that acupuncture may be a safe and effective adjuncttherapy for women undergoing IVF. There is a definite need formore thorough and carefully designed clinical trials to evaluatethe effect of acupuncture on IVF success rates.

POTENTIAL MECHANISMS UNDERLYING ACUPUNCTURE'SIMPACT ON FERTILITY AND IN VTTRO FERTILIZATIONSUCCESS RATES

Understanding the mechanism by which acupunctureimproves IVF success rates is important because it defines appro-priate outcome measures that should be evaluated in future clini-cal trials assessing the use of acupuncture with IVF. It alsofurthers our understanding of how acupuncture modulates specific physiological processes, which could lead to a more targetedapproach to identifying women who would specifically benefitfrom acupuncture while undergoing IVF.

Drawing on a broad body of literature evaluating the mech-anistic basis of acupuncture as well as our understanding of thephysiological basis of female fertility, we propose 4 interrelatedmechanisms by which acupuncture could improve the outcomeof IVF: (1) modulating neuroendocrinological factors; (2)increasing blood flow to the uterus and ovaries; (3) modulatingimmune factors, especially cytokines; and (4) reducing stress,anxiety, and depression.

Acupuncture and the Hypothalamus-Pituitary-Gonadaland -Adrenal Axes

The hypothalamus releases a range of hypophysiotrophichormones, several of which are directly or indirectly importantfor fertility: gonadotropin-releasing hormone (GnRH), corti-cotrophin-releasing hormone (CRH), growth hormone-releasinghormone (GHRH), and thyroid-releasing hormone (TRH). Thesehormones act on the pituitary gland to regulate its own hormoneproduction." GnRH regulates the production of FSH and luteiniz-ing hormone (LH), which in turn regulates the activity of the

ovaries and their production of estrogen and progesterone. Theovarian steroid hormones then provide a feedback mechanism toregulate the hypothalamus. The connection of the hypothalamus-pituitary-gonads is called the HPG axis. Likewise, CRH regulatesthe production of adrenocorticotrophic hormone (ACTH), whichin turn regulates the secretion of cortisol by the adrenal gland.Cortisol can then negatively feed back on the hypothalamus andpituitary gland to control the further production of both ACTHand CRH. The connection of the hypothalamus-pituitary-adrenalgland is called the HPA axis. Both of these axes play importantroles in reproductive function." The production of GHRH andTRH and the physiological functions that they regulate also canplay an important role in fertility."

Many reproductive problems are related to abnormalities inhypothalamic and pituitary function. These can be caused bystructural abnormalities such as tumors; genetic mutations(either acquired or congenital); lifestyle factors (such as poornutrition, excessive exercise, smoking, obesity, and chronicstress); and psychological factors (such as eating disorders anddepression). The HPA axis is intimately involved in the negativeeffects that stress has upon fertility. Stress elevates cortisol levels.Cortisol enhances vascular reactivity, activates the catabolism ofprotein and fat to provide energy, and inhibits insulin activity.Chronic exposure to stress and elevated cortisol levels inhibitnonessential processes such as reproduction.

Precisely how acupuncture can affect neuroendocrinologicalfactors is not known. It is well established, however, that EAinhibits pain perception by elevating several classes of neuro-chemicals," including (3-endorphin.'' The ability of acupunctureto affect a range of cellular and physiological functions is attrib-uted to this modulation of neurochemicals. These substancesthen influence a range of hypothalamic functions and affectreproduction, autonomic function, and even the immune sys-(gj^ 14,45,46 j j ] g jjggj^ suggested that acupuncture acts to modulate

both the HPG'""'"' and HPA*"" axes.

Recent studies have demonstrated that EA can alter severaldifferent neuroendocrinological factors that are important deter-minants of female fertility. Stener-Victorin et al showed that low-frequency (2 Hz) EA treatment induced regular ovulation in onethird of women with anovulation associated with polycystic ovarysyndrome (PCOS).'" Using a rat model of steroid-induced PCOS,low-frequency EA has been shown to reduce elevated ovariannerve growth factor, corticotrophin-releasing factor, and endothe-lian concentrations"™ and to increase concentrations of hypothal-amic P-endorphin.' ^ This appears to result from a modulation ofthe sympathetic nerve activity in the ovary' ' and allows EA to nor-malize most of the steroid-induced changes in ovarian adrenocep-tors and to prevent steroid-induced up-regulation of thelow-affinity p75 neurotrophin receptor."

Acupuncture and Uterine and Ovarian Blood FlowAdequate blood flow to the developing ovarian follicle and

decidualized endometrium is essential to the initiation and main-tenance of normal human pregnancy. Doppler ultrasound evalua-

44 ALTERNATIVE THERAPIES. MAY/JUNE 2007. VOL 13. NO. 3 In Vitro Fertilization and Acupuncture

tion of uterine and ovarian blood flow has demonstrated thatimproved blood flow in either vascular system is associated withimproved fertility outcomes, although follicular flow measure-ments are more closely correlated with improved fertility out-comes.''" Blood flow impedance in the uterine arteries expressedas a resistance index, the pulsatility index (PI), is considered valu-able in assessing endometrial receptivity. A high uterine artery PIis associated with a decreased pregnancy rate following IVF-embryo transfer.''"''"

The use of ultrasound guidance for the retrieval of oocytesduring IVF cycles has demonstrated that the systolic velocity ofblood flow to a particular ovarian follicle was directly associatedwith the ability to retrieve an oocyte from that follicle." Womenwho respond poorly to ovarian stimulation for IVF have compro-mised blood flow to their ovarian follicles (and uteri) when com-pared to women with normal ovarian responses.'"' The levels ofthe vasoactive protein vascular endothelial growth factor (VEGF)in the follicular fluid of poor responders is higher than that ofnormal responders, and levels are inversely related to the subse-quent quality of the embryo that is produced by the retrieved egg.VEGF promotes angiogenesis and is produced and secreted inresponse to hypoxia. High levels of VEGF in the follicular fluidcan be used to identify poor follicular development."

Acupuncture has been shown to modulate the circulation ofblood in many different parts of the body. Studies have shownthat acupuncture can alter cerebral blood flow'^" and peripheralblood flow.'''''The efficacy of acupuncture in the treatment ofseveral disorders, including migraine headaches,*' cerebralischemia,™" and fibromyalgia," has been proposed to be mediat-ed by its effects on blood flow.

In a study by Stener-Victorin et al. repeated EA treatments in10 infertile women resulted in a significantly decreased PI of theuterine arteries." This decrease was sustained for 10-14 days afterthe EA treatment period. Latter studies in rats by the same groupshowed that low-frequency EA increased ovarian blood flow as areflex response via the ovarian sympathetic nerves.^'" In contrast,high-frequency EA decreased ovarian blood flow following sys-temic circulatory changes in both normal rats and rats with PCOS.Acupuncture also has been shown to modulate the production ofseveral angiogenic factors, such as endothelin-150 and VEGF."

Acupuncture and CytokinesA growing body of literature supports a role between certain

soluble mediators of immune responses and the achievement andmaintenance of pregnancy. A brief description of the classifica-tion of these factors is presented, followed by a discussion of theirputative role in fertility.

T helper cell phenotypes have been subcategorized based onthe cytokine secretory profiles of CD4-I- cells. Thl cells promoteinflammation via the secretion of inflammatory cytokines (eg,interferon [IFN] gamma, interleukin [IL]-2, IL-12, IL-18), whereasTh2 cells promote allergic-type responses, including mast cell andeosinophil activation and antibody production. Cytokine secretionassociated with Th2 responses involves IL-4, IL-6, IL-10, and IL-13.

Th3 responses are characterized by the secretion of transforminggrowth factor beta (TGFP). Development of these phenotypesbegins with the naive T helper progenitor (Thp) cell. Cytokinesand chemokines in the environment where Thp cells encountermajor histocompatibility complex (MHC) class Il-presented anti-gen direct the development of Thl, Th2, or Th3 phenotypes.

With the exception ofa brief and immediate pro-inflammatoryresponse at the site of implantation, successful human pregnancyappears to be characterized by a local and systemic Th2 dominance;women with repeated pregnancy failure may be unable to modulatetheir T helper responses appropriately upon becoming pregnant."™T helper cytokine profiles and their modulation in pregnancy andupon exposure to pregnancy-related hormones have been studiedextensively. This includes their relationship with fertility," repeatedimplantation failure after IVF,™ and recurrent clinical pregnancyloss." T helper cell dysregulation that adversely afFects pregnancyoutcomes could be occurring systemically, at the level of theendometrium/implantation, within the microenvironment of thedeveloping ovarian follicle, or at all sites.

Several studies have demonstrated acupuncture's ability tomodulate cytokine production. It has been proposed that in thebrain, acupuncture may modulate cytokine levels via its ability toincrease the release of P-endorphin.""* Investigators have demon-strated that acupuncture normalizes Thl- and/or Th2-typecytokines in the ventral midbrains of healthy rats," in the hypo-thalami of rats with lipopolysaccharide-induced fever," and in theischemic cortices of rats with middle cerebral artery occlusion.*'Chen et al showed that EA stimulation significantly up-regulatedIL-6 mRNA levels in rat cortex and striatum following cerebralischemia/reperfusion." This may explain the neuroprotectiveeffect of acupuncture in cerebral ischemic injury. Other investiga-tors have shown similar protective peripheral cytokine modula-tion when acupuncture was used in rats with induced ulcerativecolitis"'' and in rats that had experienced operative trauma." Yu etal showed that rats receiving acupuncture had elevated levels ofIL-2 in aqueous spleen extracts."'

In humans, Jeong et al investigated the effect of acupunctureon the production of inflammatory cytokines in patients withchronic headaches and found that acupuncture resulted indecreased levels of IL-1|3 and IL-6.''" Petti et al showed thatacupuncture treatment reduced the plasma levels of IL-2 and IL-10 in subjects with chronic allergic rhinitis when compared tosubjects receiving no treatment or those receiving sham acupunc-ture." Joos et al conducted an RCT to assess the effects ofacupuncture in the treatment of allergic asthma and found thatthere was a significant reduction in the plasma levels of IL-6 andIL-10 in subjects receiving acupuncture.™ In contrast, IL-8 levelsrose significantly. Others have demonstrated similar cytokine nor-malization in patients with malignant tumors"' or rheumatoidarthritis'^ who were treated with acupuncture.

Acupuncture and Stress, Anxiety, and DepressionA significant amount of literature supports the contention

that women who experience depression while undergoing IVF

In Vitro Fertilization and Acupuncture ALTERNATIVE THERAPIES. MAY/|UNE 2007. VOL 13. NO. 3 45

have lower pregnancy rates than women who are notdepressed." " Depressive symptoms are common amongpatients who undergo IVF, and the severity and prevalence ofdepression increase as the number of IVF treatment failuresincreases." Anxiety is also correlated with pregnancy rates inIVF. Women with significant concerns about the financial costassociated with IVF were at much higher risk of not achieving asuccessful delivery.'^ A prospective study of 291 women foundthat anxiety had a stronger negative correlation with IVF out-come than did depression.'"" Another study found that womenwith episodic anxiety, but not those with trait or acute anxiety,were less likely to conceive in the second IVF attempt if the firstwas not successful.''

Stress reduction appears to enhance fertility. A randomized,controlled study of 184 women undergoing a combination ofinfertility treatments evaluated the impact of cognitive behavioraltherapy (including relaxation and yoga) on pregnancy rates.™Women undergoing cognitive behavioral therapy were comparedto those attending a standard support group and routine carecontrols. Patients with depression were excluded from the study.Pregnancy rates were significantly higher in women undergoingcognitive behavioral therapy and in those attending supportgroups when compared to the control group; treatment groupsdid not differ from one another. In a smaller study of couplesundergoing IVF,*° couples were randomized to either counselingor a control group during IVF." The group who underwent coun-seling experienced significantly lower anxiety and depressionscores, higher life satisfaction scores, and significantly higherpregnancy rates than control couples. These data make a strongcase for the use of therapies that can reduce stress and negativeemotional states in women undergoing IVF.

Studies have shown that acupuncture may be effective in thetreatment of depression,'"" anxiety,'"""^ and stress.'"^"* Gallagheret al conducted an RCT with 38 participants and concluded thatcompared to other empirically validated treatments (eg, medica-tion, talk therapy), acupuncture designed specifically to treatmajor depression produces results that are comparable in terms ofrates of response and of relapse or recurrence." In a clinical trialinvolving 30 subjects receiving acupuncture compared with 31subjects receiving drug therapy, Han et al concluded that EA canproduce the same clinical therapeutic effect as that produced bythe tetracyclic antidepressant maprotiline, with fewer side effectsand better symptom improvement." Spence et al conducted a clin-ical trial involving 18 anxious adult subjects who complained ofinsomnia.'"^ Five weeks of acupuncture treatment was associatedwith a significant nocturnal increase in endogenous melatoninsecretion and significant improvements in polysomnographicmeasures of sleep onset latency, arousal index, total sleep time,and sleep efficiency. Additionally, state and trait anxiety scoreswere lowered significantly. Middlekauff et al tested the hypothesisthat acupuncture is sympathoinhibitory in humans with heart fail-ure.'"' Fifteen advanced heart failure patients underwent acutemental stress testing before and during "real" acupuncture (n=10),non-acupoint acupuncture (n=10), or no-needle acupuncture

(n=10). During the pretreatment mental stress testing, sympathet-ic nerve activity increased significantly. This increase was eliminat-ed after real acupuncture but not after non-acupoint or no-needleacupuncture control treatments.

With regard to the use of acupuncture during the IVF proce-dure, Gejervall et al demonstrated that acupuncture significantlyreduced postoperative tiredness and confusion in women under-going oocyte aspiration for IVF. ' Stener-Victorin et al showedthat 2 hours after oocyte aspiration, the group of women receiv-ing acupuncture (at the time of oocyte aspiration) experiencedsignificantly less abdominal pain, other pain, nausea, and stressand were significantly calmer than those in the control group,who had received conventional analgesia.^'

The mechanistic basis for the effects of acupuncture ondepression, anxiety, and stress are not well understood. A num-ber of possibilities have been suggested, however, includingmodulation of neuropeptide Y levels in the amygdala,^' increasedproduction of opioid peptides,'"'''"' attenuation of the sympathet-ic nervous system,'"'" enhanced vagal nervous activity,'" andrestoration of hippocampal brain-derived neurotrophic factorlevels.'"' It also has been proposed that acupuncture may influ-ence the HPA axis and thereby alter many of the physiologicalresponses to stress.*'"

CONCLUSIONThere is a growing body of literature to support an under-

standing of how acupuncture may alter several physiological andpsychological processes. This literature helps to define the mostprobable mechanistic pathways that are relevant to understandingthe use of acupuncture for IVF. However, many of the mechanisticstudies presented here were not designed to directly investigateacupuncture mechanisms as they relate to female infertility or IVF.Therefore, an important next step in understanding the mechanis-tic basis of acupuncture as an adjunct therapy for IVF is a targetedinvestigation of the effects of acupuncture therapy during IVF.

Although methodological problems with the existing clini-cal research significantly limit their conclusions, the studiesreviewed in this article suggest that acupuncture may be a safeand effective adjunct therapy for women undergoing IVF. Giventhat many women use acupuncture during IVF therapy, there is ahighly justified need for more definitive clinical trials investigat-ing the use of acupuncture for improving IVF outcomes. A quali-ty clinical trial investigating this issue would have the followingcharacteristics: randomization, blinding, sham acupuncture con-trol, an acupuncture treatment protocol that is consistent withTCM principles, a range of outcome measures representative ofboth clinical outcomes and putative mechanistic processes, andcompliance with rigorous statistical standards and other guide-lines specified by STRICTA.

Such studies will provide a greater understanding of the clin-ical applicability of acupuncture, may allow more specializedusage for specific infertility conditions, and will enhance the cred-ibility and integration of acupuncture in conventional Westernmedical settings.

46 ALTERNATIVE THERAPIES. MAY/JUNE 2007. VOL. 13. NO. 3 In Vitro Fertilization and Acupuncture

Acknowledgments'I'he research described in (his paper wss supported by Gram Niiniber 5 U19 AT002022 from

Ihe Naiional histilutes of Health (Nlll). National Center for Complementary and Alternative

Medicine (NCCAM). This grant was awarded to the New Ungland School ofAeupuneture, 40

Relmont St. Watertown. MA 02472. USA. Its contents are solely the responsibility of the

antliors and do not necessarily represent the official views of the NCCAM or the NIH.

The atLthors thank Drs Linda Craziadei Schust and Steve Schachter for their careful reading of

this manuscript and their helpful comments and suggestions. Gratitude is also e.xtended to

Moniea Shields and Jennifer Lewin for their assistance with compiling the reference list.

RI'Fl'RENCES1. National Center for Health Statistics. National Survey of Hamily Growth 1995.

Hyattsville. Md: Centers for Disease Control and Prevention; 1999.2. Wright VC. Schieve LA. Reynolds MA. Jeng G. Kissin D. A.ssisted Reproductive

Technology Surveillance-United States 2001. MMWRSurveillSumm. 2004:53(l):]-20.3. Olivius K. h'riden B. Lunden K. Bergh C. Cumulative prohahility of live birth after three

in vitro fertilization/intracytoplasmic sperm injection cycles. Fertil Steril.2002:77(3):505-510.

4. Kovacs GT. Madachlan V. Brehny S. What is the probability of conception for couplesentering an IVF program? Aust NZJ Ohstet Cynaecol. 2001 -.41 (2):207-209.

.S. US Department of Health and Iluman Services. 2001 Assisted ReproductiveTechnology Succe.ss Kates. Available at: http://ww%v.cdc.gov/ART/AKr01/index.htm.Accessed March 16.2007.

(i. Collins JA. Bustillo M. Visscher RD. Lawrence I.D. An estimate of the cost ofin vitrofertilization services in the United States in 1995. EertilSteril. 1996;64(3):538-545.

7 Collins J. An international survey of the health economics of IVI' and ICSI. Hum ReprodUpdate. 2002:8(3):265-277

8. Jain T. Harlow BL. Hornstein MD. Insurance coverage and outcomes ofin vitro fertil-ization. NEnglJMed. 2002;347(9):661-666.

9. Schenker JG. Meirow D. Schenker II. Stress and human reproduction. European JOhstet Gyneeol Reprod Riol. 1992;45(l):l-8.

10. Cwikel J. Gidron Y. Sheiner I;. P.sychological interactions with infertility amongwomen. EiirJ Ohstet Gynecol Reprod Biol. 2004; LI7(2): 126-131.

11. Demyttenaere K. Bonte L. Gheldof M. et al. Coping style and depre.ssion level infln-ence outcotne in fertilization. Eertil Steril. 1998:69(6): 1026-1033.

12. KlonofT-Cohen IL Natarajan L. The concerns during assisted reproductive technolo-gies (CART) scale and pregnancy outcomes. FertilSterii. 2004;81(4):982-988.

13. Beal MW. Women's use of complementary and alternative therapies in reproductivehealth care.J Nur.seMidwifery. 1998:43(3):224-234.

14. StraussJ. BarbieriR. Yen mdJiiffe's Reproductive Endocrinology: Physiology. Pathophysiologyand Clinical Management. 5th ed. Philadelphia. Pa: \V B Saunders Co: 2004.

1.5. Nestler G. Dovey M. Traditional Chinese medicine. Clin Ohstet Gynecol.2001:44(4):801.813.

16. Birch SJ. I'elt RL. Understanding Acupuncture. London: Churchill Livingstone: 1999.17. Langevin HM. Yandow J A. Relationship of acupuncture points and meridians to con-

itective tissue planes. Anat Rec. 2002:269(6):257-265.18. Ahn AC. Wu J. Badger GJ. Hannnerschlag R. Langevin HM. lilectrical impedance along

connective tisstie planes associated with acupuncture meridians. BMC Complement/1/(m/M«/.2005May9;5:10.

19. Maciocia. G. Ohstetries and Gynecolog)' in Chinese Medieine. London: ChurchillLivingstone: 1998.

20. Lyttleton. J. Treatment of Infertility with Chinese Medieine. London: ChurchillLivingstone: 2004.

21. Liang. I. Acupuncture and IVF. Boulder: Blue Poppy Press: 2003.22. Schnyer RN. Allen JJ. Bridging the gap in complementary and alternative medicine

research: manualization as a means of promoting standardization and flexibility oftreatment in clinical trials of acupuncttire.y/l//miC()m/;/i'mra/Mi'rf.2002:8(5):623-634.

23. Paulus WE. Zhang M. Strehler E. El-Danasouri 1. Sterzik K. Inlluence of acupunctureon the pregnancy rate in patients who undergo assisted reprodtiction therapy. Fertil,V/m';.2002:77(4):72l-724.

24. Dieterle S. Ying G. Hatzmanti W, Neuer A. Effect of acnpnncttire oti the outcome ofinvitro fertilization and intracytoplasmic sperm injection: a randomized, prospective,controlled clinical study, fir//;6'/m7. 2006:85(5): 1347-1351.

25. Smith C. Coyle M. Norman RJ. Influence of acuptmcture stimulation on pregnancyrates for wonien undergoing embryo transfer. FertilSterii. 2006:85(5): 1352-1358.

26. Westergaard LG. Mao Q, Krogslund M. Sandrini S. Lenz S. Grinsted J. Acupuncture onthe day of embryo transfer significantly improves the reproductive outcome in infertilewomen: a prospective, randomized trial. FertilSterii. 2006:85(5):1341-1346.

27 Stener-Victorin E. Waldenstrom U. Niisson L. Wikland M. Janson PO. A prospectiverandomized study of electro-acupuncture versus alfentanil as anae.sthesia duringoocyte aspiration in in-vitro fertilization. Hum Reprod. l999:14(10):2480-2484.

28. Stener-Victorin E. WaldenstroiTi U. Wikland M. Niisson L. I lagglund L. Lundeberg T.Electro-actipuncture as a peroperative aitalgesic method aEid its efl'ects on implantationrate and neuropeptide V concentrations in follicular fluid. Hum Reprod.2003;18(7):1454-1460.

29. Gejervall AL. Stener-Victorin E. Moller A. Janson PO. Werner C. Bergh C. Eiectro-acupuncture versus conventional analgesia: a comparison of pain levels during oocyteaspiration and patients' experiences of well-being after stirgery. Hum Reprod.20(15:20(3):728-735.

30. Hnmaidan P. Brock K. Bungum L. Stener-Victorin E. Pain relief during oocyteretrieval—exploring the role of difl'erent freqtiencies of electro-acnptuicture. Reprodftomn/O«/mf. 2006:13(0:120-125.

31. BalkJ. Kairo B, Roberts JO. Electroactipuncture in infertile patients receiving in-vitrofertilization and embryo tran.sfer: a pilot study. Medical Acupuncture. 2003:14(3):12-14.Available at: http://www.medicalacupuncture.org/aama_marf/jotirnal/volMJVarti-clel.html. Accessed I'ebruary 21.2007.

32. Enmions S. Patton P. Actiptincture treatment for infertile wonien undergoing iittracy-toplasmic sperm itijection. Medical Acupuncture. 2000:12(2):18-20. Available at:http://www.medicalacuputicture.coni/aaitia_ntarf/jonnial/voll2_2/articlel.htnil.Accessed February 21. 2007

33. Johnson D. Acupunettire prior to and at emhryo transfer in an assisted conceptiontuiit-a case .series. Acupunet Med. 2006:24( l):23-28.

34. Lao L. Hamiltoti GR, Fu J. Berman BM. Is acupunettire safe'/ A .systematic review ofcase reports. Altern Ther Health Med. 2003.9(l):72-83.

35. White A. A cumulative review of the range and incidence of signiflcant adverse eventsassociated with acupuncture. Acupunet Med. 2004.22(3): 122-133.

36. Kaptchuk TJ. The placebo eff'ect in alternative medicine: can the performance ofa heal-ing ritual have clinical significance?/1/m Intern Med. 2002:136(1 l):8l7-825.

37. Birch S. Controlling for non-speciflc efl'ects of acupuncture in clinical trials. ClinicalAcupuncture and Oriental Medieine. 2003:4(2-3):59-70.

38. Domar. AD. Acnpnncttire and ittfertility: we need to stick to good science. Eertil Steril.2006:85(5):13.';9-136l.

39. Myers ER. Actipunctnre as adjunctive therapy in assisted reproduction: remaininguncertainties. FertilSterii. 2006:85(5):t362-1363.

40. Collins J. The play of chance. Fertil Steril. 2006:85(5): 1364-1367.41. Schnyer RN. Wayne PM. Kaptchuk TJ. Cheng X. Zhang Z. Sta.son WB. Standardization

of individualized treatments in a randomized controlled trial of acupuncture for strokerehabilitation.y/l/(m) Com/j/rami/Afcrf. 2006;12(2):106-109.

42. MaePherson H. White A. Cummings M. Jobst K. Rose K. Nietntzow R. Standards forreporting interventions in controlled trials of acupuncture: the STRICI'A recommenda-tions. Complement Ther Med. 2001:9(4):246-249.

43. Han JS. Acnpuncttire: netiropeptide release produced by electrical stimtilation of differ-ent frequencies. Trends Neurosei. 2003:26(l):17-22.

44. Han JS. Acupunettire and endorphins. Neurosei Lett. 2004:361(l-3):258-26l.45. Zijistra FJ. van den Berg-de Lange 1. Huygen FJ. Klein J. Anti-inllantniatory actions of

acupuncture. Mediators Inflamm. 2003:12(2):59-69.46. Blalock JE. Proopiomelanocortin and the immune-neuroendocrine connection. Ann N

YAcmlSci. 1999 Oct 20:885:161-172.47. Stener-Victorin E. Lundeberg T. Waldenstrom U. Bileviciute-Ljungar 1. Janson PO.

Eff'ects of electro-acuptincture on corticotropin-reieasing factor in mts with experimen-tally-induced polycystic ovaries. Neuropeptides. 2001;35(5-6):227-231.

48. Cho ZH. Hwang SC. Wong EK. et al. Neural stibstrates. experimental evidences andfunctional hypothesis of aeupuncture mechanisms. Acta Neurol Scand.2006:n3(6):370-377

49. Zhang RX. Lao L, Wang X. et al. Eiectroacupuncture attentiates inflammation in a ralmodd.J Altern Complement Med. 2005:Ll(l):135-142.

50. Stener-Victorin E. l.tindeberg T. Cajander S. et al. Steroid-induced polycystic ovaries inrats: effect of electro-acupuncture on concentrations of cndotheIin-1 and nerve growthfactor (NGF). and expression of NGE niRNA in the ovaries, the adrenal glands, and thecentral nervous .system. Reprod Biol Endoerinol. 2003 Apr 8:1:33.

51. Stener-Victorin E. Waldenstrom U. Tagnfors U. Lundeberg 'f. Lindstedt G. Jattson PO.Effects of eleetro-actipuncture on anovulation in women with polycystic ovary .syn-drome./Ifte Ohslet Gyneeol Seand. 2000:79(3): 180-188.

52. Stener-Victorin E. l.indholin C. Immunity atid heta-eiidorphin concentrations in hypo-tlialamns and plasma in rats with steroid-induced ])olycyslic ovaries: eff'ect of low-fre-quency eiectroacupuncture. Bioi Reprod. 2004:70(2):329-333.

53. Stener-Victorin E. Kobayashi R. Watanabe O. Lundeberg T. Kurosawa M. Ell'cct of elec-tro-acupuncture stimulation of diff'erent frequencies and intensities on ovarian bloodflow in anaesthetized rats with steroid-induced polycystic ovaries. Reprod BiolEndocrinol. 2004 Mar 26:2:16.

.54. Manni L. Lundeberg T. Holmang A. Aloe L. Stener-Victorin E. Effect of eiectro-acupuncture on ovarian expre.ssion of alpha (1)- and beta (2)-adretioceptors. and p75neurotrophin receptors in rats with steroid-induced polycystic ovaries. Reprod Biollindocrinol.2005 jm7.3:2\.

55. Seraflni P. Batzoi'm J. Nelson J. Olive D. Sonograpliic uterine predictors of pregnancy inwonien undergoing ovtilation induction for assisted reproductive treatments. FertiiSteril. 1994:62(4):815-822.

56. Kim KH. Oh DS. Jeong JH. Shin BS. Joo BS. Lee KS. Follicular hlood flow is a hetter pre-dietor of the outcome ofin vitro fertilization-embryo transfer than follicular fluid vas-cular endothelial growth factor and nitric oxide concentrations. Fcrtil Steril.2004:82(3):586-592.

v57 Battaglia C. Genazzani AD. Regnani G. Primavera MR. Petraglia F. Voipe A.Perifollicular Doppler flow and follicular ffuid vascular endothelial growth factor con-centrations in poor responders. FertilSterii. 2000:74(4):809-812.

58. Sterzik K. Grab D. Sasse V, Mutter VV. Rosenbtiscli B. Terinde R. Doppler sonograpliicffndings and their correlation with implantation in ati in vitro fertilization program.;'frt/75(m7. 1989:52(5):825-828.

59. Steer CV. Campbell S. Tan SL. et al. The u.se of transvaginal color flow imaging after invitro fertilization to identify optimum uterine conditions before embryo transfer. FertitSteril. 1992:57(2):372-376.

hi Vitro Fertilizatioti attd ActtpttticUire ALTERNATIVE THERAPIES. MAY/|UNE 2007. VOL. 13. NO. 3 47

60. Nargnnd G. Bonrne T. Doyle P. et al. Associations between ultrasound indices of follic-ular blood flow, oocyte recovery and preimplantation embryo quality. Hum Reprod.1 9 9 6 ( l ) 0 9

61.

62.

63.

64.

65.

66.

67.

68.

69.

70.

71.

72.

73.

74.

75.

76.

77.

78.

79.

80.

81.

82.

84.

85.

86.

87.

88.

89.

90.

Barroso G. Barrionuevo M. Rao P. et al. Vascular endothelial growth factor, nitricoxide, and leptin follicuiar fluid levels correlate negatively witb embryo quality in IVFpatients. FertilSterii. 1999:72(6): 1024-1026.

Newberg AB. Lariccia PJ. Lee BY. I'arrar JT. Lee L. Alavi A. Cerebral blood flow effectsof pain and acupuncture: a prelitTiinary single-photon emission computed tomographyimaging study.//Vraro/m(j^mj;.2005:15(l):43-49.

Lee JD. Chon JS. Jeong HK. et al. Tbe cerebrovascular response to traditional acupunc-ture after stroke. Neuroradiology. 2003:45(]l):780-784.

Backer M. Hammes MG. Valet M. et al. Different modes of mannal acupuncture .stimu-lation differentially modulate cerebral blood flow velocity, arterial blood pre.ssure andbeart rate iti bnman subjects. Neurosei Lett. 2002;333(3):203-206.Sandberg M. Lundeberg T. Lindberg LG. Gerdie B. Effects of acupuncture on skin andnin.scle blood flow in bealtby snbjects. EurJAppl Physiol. 2003:90(l-2):l 14-119.Sandberg M. Lindberg LG. Gerdie B. Peripheral effects of needle .stimulation (acupunc-ture) on skin atid muscle blood flow in tibromyalgia. EurJ Pain. 2004;8(2):163-171.Noguchi E. Obsawa H. Kobayasbi S. Sbitnura M. Ucbida S, Sato Y. The effect of electro-acupuncture stimulation on tbe niuscie blood flow of the bindlimb in anestbetizedTMs.JAuton NervSyst. 1999:75(2-3):78-86.

Loaiza LA. Yatnagucbi S. Ito M. Obsbima N. Electro-acupuncture stimulation to mus-cle afferents in anestbetized rats modulates the blood flow to the knee joint throughautonomic reflexes and nitric oxide. Auton Neurosei. 2002:97(2): 103-109.Backer M. Hammes M. Sander D. et al. Changes of cerebrova.sctilar respon.se to visualstimulation in migraineurs after repetitive sessions of somatosensory stimulation(acupuncture): a pilot study. Headache. 2004:44(l):95-101.

Wang SJ. Omori N. Li F. et al. Functional improvement by electro-acupuncture aftertransient middle cerebral artery occlusion in rats. Neurol Res. 2003:25(5):516-521.Gao H. Guo J. Zhao P. Cheng J. The neuroprotective effects of eiectroacupuncture onfocal cerebral iscbemia in monkey. Acupunet Electrothcr Res. 2002:27(]):45-57.Stener-Victorin E. Waldenstrotii U. Andersson SA. Wikland M. Rednction of bloodflow impedance in tbe uterine arteries of infertile women with electro-acupuncture.Hum Reprod. 1996:11(6):1314-1317.

Stener-Victorin E. Kobayashi R. Kuro.sawa M. Ovarian blood flow re.sponses to electro-acupuncture stimulation at different frequencies and intensities in anaestbetized rats.Auton Neurosei. 2003:108(l-2):50-56.

Wang SJ. Omori N. Li F. et al. Functional improvement by electro-acupuncture aftertransient titiddle cerebral artery occlusion in rats. Neurol Res. 2003:25(5):516-521.Bermas BL. Mill JA. Proliferative respon.ses to recall antigens are associated witb preg-

nancy outcome in women with a bistory of recurrent spontaneous abortion./ ClinInvest. 1997:100(6):1330-1334. Erratum m:J Clin Invest. 1998:101(2):513.Haimovici F. Flill JA. The role of psycbo-neuro-endocrine-itnmtinology in reproduc-tion. In: Cytokines in Reproduction. Hill JA. ed. New York: Wiley-Liss: 2000:1-16.Litn KJ. Odukoya OA. Ajjan RA. Li TC. Weetman AP. Cooke ID. The role of T-beipercytokines in human reproduction. Fertit Steril. 2000:73(l):136-142.Kwak-Kim JY. Cbung-Bang MS. Ng SC. et al. lncrea.sed T helper 1 cytokine respon.ses bycirculating T cells are pre.sent in women with recurrent pregnancy losses and in infertilewomen with multiple implantation failures after IVF. Hum Reprod. 2003:18(4):767-773.Scbust DJ. Mill JA. Correlation of serum cytokine and adbesion tiiolecule determina-tions with pregnancy outcome./5f)f Gynecot Investig. 1996:3(5):259-261.Bonta IL. Acupuncture beyond tbe endorph in concept? Med Hypotheses.2002:58(3):221-224.

Liu XY. Zbou HF. Pan YL. et al. Electro-acupuncture stimulation protects dopaminer-gic neurons from inflammation-mediated damage in medial forebrain bundle-tran.sect-ed rats. F.xp Neurol 2004:189(]):189-196.

Son YS. Park HJ. Kwon OB, Jung SC. Sbin HC. Lim S. Antipyretic effects of acupunc-ture on the lipopoly.saccbaride-induced fever and expre.ssion of interleukin-6 and inter-leukin-1 beta mRNAs in tbe hypothalatiius of rats. Neurosei Lett. 2002:319(l):45-48.Xu ZF. Wu CC. Cao XD. Effect of eiectroacupuncture on the expre.ssion of interlukin-lbeta mRNA after transient focal cerebral iscbemia. Acupunet Eleetrother Res.2002:27(]):29-35.Cben J. Huang C. Xiao D. Cben HP. Cbeng JS. Expression of interleukin-6 mRNA inischetnic rat brain after eiectroacupuncture stimulation. Acupunet Eleetrother Res.2003:28(3-4):157-166.

Wu HG. Zhou LB. Pan YY. et al. Study of the mechanisms ol acupuncture and moxi-bustion treattitent for ulcerative colitis rats in view of tbe gene expre.ssion of cytokines.World J Gastroenterol. 1999:5(6):515-517.Cbeng XD. Wu GC. He QZ. Cao XD. Effect of continued eiectroacupuncture on induc-tion of interleukin-2 production of spleen lympbocytes frotit the itijured rats. AeupunetEleetrother Res. l997:22(l):l-&.Yu Y. Kasahara T. Sato T. et al. Enhancement of splenic interferon-gamma, interleukin-2, and NK cytotoxicity by S36 acupoint acupuncture in F344 tats. Jpn J Physiol.1997:47(2):173-I78.

Jeong HJ, Hong SH. Nam YC. et al. The effect of acupuncture on proinflammatorycytokine production in patients witb chronic beadache: a prelitninary report. AmJChin Med. 2003:31(6):945-954.

Petti FB. Liguori A. Ippoliti F. Study on cytokines IL-2. IL-6. IL-10 in patients of chronicallergic rhinitis treated with acupuncture./ Tradit Chin Med. 2002:22(2):104-lll.Joos S. Schott C. Zou H. Daniel V. Martin E. Immunomodulatory effects of acupunc-ture in tbe treatment of allergic asthtita: a randomized controlled study. J Altern

Complement Med. 2000:6(6):519-525.

91. Wu B. Zhou RX. Zhou MS. Effect of acupuncture on ititerletikin-2 level and NK cellimmunoactivity of peripberal blood of malignant tumor patietits. Zhon^uo Zhong Xi 17JieHeZaZhi. 1994:14(9):537-539.

92. Xiao J. Liu X. Sun L. et al. Experimental study on tbe itifluence of actipuncture andmoxibustion on interleukin-2 in patients witb rbeutnatoid arthritis. Zhen Ci Yanjiu.1992:17(2):126-128.132.

93. Thiering P. Beaurepaire J. Jones M. Saunders D. Tetinant C. Mood state as a predictorof treatment ontcotiie after in vitro fertilization/etiihryo tran.sfer technology. /Psyehosom Res. 1993:37(5):481-491.

94. Smeenk JM. Verbaak CM. Eugster AM. vati Minnen A. Zielbtiis GA. Braat DD. Tbeeffect of anxiety and depression on tbe outcotne of in-vitro fertilization. Hum Reprod.2001:16(7):1420-M23.

95. Eugster A. Vingerboets AJ. van Heck GL. Merkus JM. Tbe effect of episodic atixiety otian in vitro fertilization and intracytoplasmic spenn itijectioti treatment outcome: apilot study./ Psyehosom Ohstet Gynaeeol. 2004:25:57-65.

96. Domar AD. Clapp D. Slawsby EA. Du.sek J. Kessel B. Freizitiger M. Itnpact of grotippsycbological interventions on pregnancy rates in itifertile wotiien. Fertil Steril.2000:73(4):805-811.

97. Terzioglu F. Investigation into effectiveness of counseling oti assisted reproductivetecbniques in Turkey./ Psyehosom Ohstet Gynaeeol. 2001:22(3): 133-141.

98. Gallagber SM. Allen JJ. Hitt SK. Scbnyer RN. Manber R. Six-tnonth depre.ssionrelapse rates atiiong women treated with acupuncture. Complement Ther Med.2001:9(4):216-218.

99. Han C. Li X. Luo H. Zhao X. Li X. Clinical sttidy on electro-acnptiticture treattnetit for30 cases of tnental depre.ssion./ Tradit Chiu Med. 2004:24(3): 172-176.

100. Tsay SL. Cho YC. Cben ML. Acupressure atid Tratiscutatieotis Electrical AcupointStimulation in improving fatigue, sleep quality and depre.ssion in bemodialysispatients. AmJ Chin Med. 2004:32(3):407-416.

101. Paraskeva A. Melemeni A. Petropoulos G. Siafaka I. Fa.ssoulaki A. Needlittg of tbe extra 1point decreases BIS values and preoperative anxiety. AmJ Chin Med. 2004:32(5):789-794.

102. Spence DW. Kayutnov L. Cben A. et al. Acupuncture increases nocturnal melatonin.secretion and reduces insotiinia and anxiety: a preliminary report./ NeuropsychiatryClin Neurosei. 2004:16(l):19-28.

103. Middlekauff HR. Hui K. Yu JL. et al. Actiptincture inbibits .sympathetic activation dur-ing mental stress in advanced heart failure patients./ Card Fad. 2002:8((i):399-406.

104. WangJD. KuoTB. YangCC. An alternative method to enhance vagal activities and stip-pre.ss .sympatbetic activities in hnmans. Auton Neurosei. 2002:100(I-2):90-95.

105. Yun SJ. Park HJ. Yeom MJ. Hahin DH. Lee HJ. Lee EH. Effect of eiectroacupuncture onthe .stre.s.s-induced changes in brain-derived iietirotropbic factor expression in rat hip-pocampus. Neurosei Lett. 2002:318(2):85-88.

106. Han SH. Yoon SH. Cho YW. Kim CJ. Min BL Inhibitory effects ol electroacupuncttireon stress responses evoked by tootb-pulp stimulation in rats. Physiol Behav.1999:66(2):217-222.

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