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Abstract

Acupuncture is increasingly being used in reproductive medicine. This review summarizes the evidence of acupuncture in pain relief for oocyte retrieval, improving pregnancy outcomes of in vitro fertilization treatment, management of ovulation disorders, male subfertility, primary dysmenorrhea, endometriosis and menopausal symptoms. However, most of the studies are nonrandomized uncontrolled trials, case reports or case series. For randomized controlled trials, the sample size is underpowered and blinding of assessors is lacking. Different acupuncture protocols and controls are used. These heterogeneities make it difficult to compare studies and draw any firm conclusions. Further studies should also evaluate the cost-effectiveness of acupuncture and investigate the underlying mechanism of acupuncture treatment.

Keywords

acupuncture anovulation dysmenorrhea endometriosis IVF male subfertility menopause sexual dysfunction

Acupuncture is an integral part of traditional Chinese medicine (TCM), which dates back more than 3000 years. In recent years, the use of acupuncture as an adjuvant treatment to the management of various obstetrical and gynecological conditions has gained increasing popularity worldwide. Moreover, the number of studies that investigate the effect of acupuncture in reproductive medicine is increasing. This can also be reflected by two Cochrane reviews on the use of acupuncture in the pregnancy outcomes of IVF treatment [1] and pain relief during labor [2].

According to the principles of TCM, there are patterns of energy flow (Qi) through the body that are essential for health. Disruption of this flow in terms of energy disturbance or imbalances, organ deficiencies or excesses are believed to be responsible for the disease states such as subfertility and dysmenorrhea. Acupuncture may correct any imbalances in the flow of life force along meridians so as to cure specific diseases. The underlying mechanisms of the positive effect of acupuncture in the treatment of certain gynecological problems may be related to the central sympathetic inhibition and regulation of the function of the hypothalamic-pituitary–ovarian axis by releasing several neurotransmitters, especially endorphins, and changing the concentration of central opioids [3].

Reproductive medicine covers a wide range of areas, but most previous reviews focused on specific aspects such as dysmenorrhea and subfertility [3 –5]. This review attempts to present a much wider perspective in reproductive medicine, including pain relief for oocyte retrieval, improving pregnancy outcome of IVF treatment, the management of anovulatory and male subfertility, management of sexual dysfunction, pain relief for dysmenorrhea and endometriosis, as well as management of menopausal symptoms. The use of acupuncture in other conditions, such as pregnancy, is not within the scope of this review.

Medline, Embase and the Cochrane Library were searched from inception to February 2010 using the terms ‘acupuncture’, ‘anovulation’, ‘dysmenorrhea’, ‘endometriosis’, ‘IVF’, ‘male subfertility’ and ‘menopause’. Both prospective and retrospectives studies, in abstracts or full papers, were included. There was no language restriction.

Pain relief for oocyte retrieval

IVF treatment is a well-established assisted reproductive treatment for couples with subfertile problems and involves two minor operations: transvaginal ultrasound-guided oocyte retrieval (TUGOR) and embryo transfer (ET). TUGOR is considered to be the most painful component of IVF treatment. Conscious sedation and local analgesics are commonly used for pain relief during TUGOR [6]. However, the use of this conventional medical analgesia may be frequently associated with adverse effects, such as nausea, vomiting, tiredness and confusion. Acupuncture may provide an alternative option for pain relief as it has no systemic side effects.

Table 1 summarizes the randomized controlled studies on the effect of acupuncture for pain relief during TUGOR [7 –11]. Two systematic reviews indicate that there is a significantly lower pain score in the conventional analgesic group than in the acupuncture group [12,13]. It is concluded that acupuncture can be recommended as one of the effective analgesic methods for patients who are unable to use conventional analgesia because of side effects during and after TUGOR. Our previous systematic review demonstrated that the pregnancy rate was not improved in the above studies that evaluated the analgesic effect of acupuncture for TUGOR [14].

Table 1.

Summary of randomized controlled studies on the effect of acupuncture for pain relief in women during transvaginal ultrasound-guided oocyte retrieval.

Study (year)	Participants (n)	Interventions	Controls	Outcomes	Results	Ref.
Stener-Victorin et al. (1999)	150	PCB + EA (n = 74)	Alfentanil + PCB (n = 75)	Post-operative pain using VAS, nausea, patient satisfaction, pregnancy and live birth rates	EA provided comparable analgesic effect to conventional analgesia Pregnancy and live birth rates were higher in the EA group than in the control group	[7]
Stener-Victorin et al. (2003)	286	PCB + EA (n = 141)	Alfentanil + PCB (n = 145)	Postoperative pain using VAS, pregnancy rates	EA provided comparable analgesic effect to conventional analgesia Pregnancy and live birth rates were higher in the control group than in the EA group	[8]
Humaidan and Stener-Victorin (2004)	200	PCB + EA (n = 100)	Alfentanil + PCB (n = 100)	Pre-, intra- and post-operative pain using VAS	Significantly higher pain level, shorter hospitalization time and lower costs were found in the EA group than in the conventional analgesic group Pregnancy and live birth rates were higher in the control vs EA group	[9]
Gejervall et al. (2005)	160	PCB + EA (n = 80)	Alfentanil + PCB (n = 80)	STAI, pain and subjective expectations and experiences using VAS, time and drug consumption, as well as pregnancy rates	Pain levels were significantly higher during and after oocyte retrieval in the EA group than in the conventional analgesic group Both groups had comparable STAI wellbeing scores Pregnancy and live birth rates were higher in the control vs EA group	[10]
Sator-Katzenschlager et al. (2006)	94	PCA + AA with (n = 32) or without (n = 32) electrical stimulation	PCA + placebo AA (n = 30)	Pain intensity and subjective wellbeing using VAS, nausea and tiredness using VRS, analgesic drug requirements and pregnancy rates	AE was significantly superior in improving pregnancy rates, reducing pain levels and analgesic consumption during TUGOR compared with both AA alone and the control group	[11]

AA: Auricular acupuncture; EA: Electro-acupuncture; PCA: Patient-controlled analgesia; PCB: Para-cervical block; STAI: State Trait Anxiety Inventory

TUGOR: Transvaginal ultrasound-guided oocyte retrieval; VAS: Visual analog scale; VRS: Visual rating scale.

Improving IVF outcomes

Apart from administration of acupuncture for pain relief during TUGOR, acupuncture has also been used on the day of ET with the aim of improving the IVF outcomes. All randomized controlled studies on the effect of acupuncture administered on the day of ET are summarized in Table 2 [15 –24].

Table 2.

Summary of randomized controlled studies in women of the effect of acupuncture performed on the day of embryo transfer.

Study (year)	Participants (n)	Interventions	Controls	Outcomes	Results	Ref.
Paulus et al. (2002)	160	Acupuncture and auricular acupuncture for 25 min before and after ET (n = 80)	No acupuncture (n = 80)	Clinical pregnancy rate	Pregnancy rate was found to be significantly higher in the acupuncture vs control group	[15]
Paulus et al. (2003)	200	Acupuncture for 25 min before and after ET (n = 100)	Noninvasive acupuncture (n = 100)	Clinical pregnancy rate	No significant difference in the pregnancy rate between two groups	[16]
Dieterle et al. (2006)	225	Acupuncture for 30 min after ET and 3 days later + Chinese medical drug placed on the patient's ear for 2 days pressed twice-daily for 10 min (n = 116)	Placebo needling at points designed not to affect fertility (n = 109)	Live birth rate, ongoing and clinical pregnancy rates	Clinical and ongoing pregnancy rates of the verum acupuncture group were significantly higher than those of the control group	[17]
Smith et al. (2006)	228	Three acupuncture sessions: one on day 9 of stimulation and two sessions 25 min before and after ET (n = 110)	Placebo needling at points close to the real acupoints (n = 118)	Clinical pregnancy rate	Clinical pregnancy rates of the acupuncture and sham acupuncture groups were comparable	[18]
Westergaard et al. (2006)	300	Group I: acupuncture for 25 min before and after ET (n = 95); Group II: acupuncture for 25 min before and after ET, + 25 min 2 days after ET (n = 91)	Group III: No acupuncture (n = 87)	Clinical pregnancy rate	Clinical pregnancy rate was significantly higher in group I vs group III; no significant difference was found in the clinical pregnancy rate between groups I and II	[19]
Craig et al. (2007)	117	Acupuncture for 25 min before and after ET	No acupuncture	Biochemical and clinical pregnancy rates	Biochemical and clinical pregnancy rates were significantly higher in the control group than in the acupuncture group	[20]
Fratterelli et al. (2008)	1000	Acupuncture (n = 200), laser acupuncture (n = 202), sham laser acupuncture (n = 198) and relaxation (n = 203)	No treatment (n = 197)	Implantation rate, chemical, clinical and ongoing pregnancy rates	Implantation rates were significantly higher in the laser acupuncture group than those in other groups; no significant differences in chemical, clinical and ongoing pregnancy rates among the five groups	[21]
Moy et al. (2008)	124	Acupuncture for 25 min before and after ET	Placebo needling at points designed not to affect fertility	Chemical and clinical pregnancy rates	Chemical and clinical pregnancy rates higher in the sham acupuncture than in the true acupuncture group; not statistically significant	[22]
Domar et al. (2009)	150	Acupuncture for 25 min before and after ET (n = 78)	No acupuncture (n = 68)	Pregnancy rates, anxiety and optimism	No significant difference was found in the pregnancy rate between groups; acupuncture patients reported feeling significantly more relaxed and optimistic about treatment outcome	[23]
So et al. (2009)	370	Real acupuncture for 25 min before and after ET (n = 185)	Placebo acupuncture for 25 min before and after ET (n = 185)	Pregnancy rates	Placebo acupuncture associated with a significantly higher overall pregnancy rate vs real acupuncture	[24]

ET: Embryo transfer.

Magarelli et al. reported three retrospective studies on the outcome of IVF following acupuncture [25 –27]. They found a significant increase in pregnancy rate after acupuncture treatment and suggested that patients with good prognosis would benefit from acupuncture treatment [26,27]. Quintero et al. conducted a small randomized double-blind crossover study using a needle-like device as the sham acupuncture [28]. A total of 17 patients were recruited and only seven completed both arms of the study. There was no difference in pregnancy rate between the two groups, but the amount of gonadotrophin used was significantly reduced following acupuncture.

So far, six meta-analyses have been published on the role of acupuncture in IVF treatment [1,14,29 –32]. Three of these showed an improvement of pregnancy rate and live birth rate following acupuncture on the day of ET [1,14,29], while the remaining could not find any differences in pregnancy rate and live birth rate between the acupuncture group and the control group [30 –32]. Different inclusion criteria were used in those review studies. No consensus on the effect of acupuncture in IVF treatment can be drawn.

Management of anovulatory subfertility

Chen and Yu showed that electro-acupuncture induced ovulation in six out of 13 anovulatory cycles as well as higher hand skin temperature and lower blood radioimmunoreactive β-endor-phin concentrations in acupuncture-induced ovulation cycles [33]. Gerhard and Postneck demonstrated that infertile women with hormonal disturbances and anovulation treated with auricular acupuncture had similar pregnancy rates but lesser side effects when compared with those treated with hormones [34].

Mo et al. reported that manual acupuncture treatments (average: 30 sessions) normalized the hypothalamic–pituitary–ovarian axis, regulated ovulation and thus improved the pregnancy outcome in women with ovulatory dysfunction [35]. Cai showed that one single acupuncture or two to three sessions of needling induced ovulation in ten out of 11 gonadotrophin-induced cycles, and suggested that acupuncture could be used as a substitution for human chorionic gonadotrophin in triggering ovulation with no occurrence of ovarian hyperstimulation syndrome [36].

Stener-Victorin et al. demonstrated that consecutive electro-acupuncture treatments improved the ovulation rates in nine out of 24 anovulatory women with polycystic ovary syndrome [37]. Previous in vivo studies from the same group demonstrated that low-frequency electro-acupuncture normalized the expression of sympathetic markers and modulated the ovarian blood flow as a reflex response via the ovarian sympathetic nerves [38,39].

Stener-Victorin et al. demonstrated that low-frequency electro-acupuncture inhibited a hyperactive sympathetic nervous system in women with polycystic ovary syndrome, which may have a beneficial effect on ovulation and fertility [40].

However, none of the studies on the management of ovulation disorders are randomized, and firm conclusions cannot be drawn. Randomized controlled studies are urgently needed in this area.

Management of male subfertility

Male factors may account for at least 30–50% of causes of subfertility and are one of the dominant causes [41]. Specific causes of male subfertility are few and should be managed by medical or surgical approaches. Despite advances in the understanding of spermatogenesis, many causes are idiopathic, and thus very few effective treatments are available. The use of assisted reproduction technology is usually the ultimate option for these situations [42 –43]. Oldereid et al. reported that approximately 20% of subfertile men may seek help from complementary and alternative medicine, including acupuncture [44]. Several uncontrolled trials reported that acupuncture treatment had a positive effect on semen parameters [45 –48] and fertilization rate [49].

Siterman et al. conducted a case-controlled study to investigate the effect of acupuncture on 16 subfertile males with poor semen quality [50]. These men received ten acupuncture treatments (25 min per session, twice a week for 5 weeks). Specific individualized combinations of designated acupoints were selected for each subject according to the TCM principles. A total of 16 subfertile males matched with age, andrological profile and subfertile history were selected as untreated controls. The percentage of viability, total functional sperm fraction, total motile sperm count per ejaculate and integrity of the axonema were significantly higher 1 month after acupuncture when compared with those of controls.

The same group also conducted a similar pilot study in patients with very poor sperm density [51]. The treatment group consisted of three severely oligoteratoasthenozoospermic, two pseudoazoospermic and 15 azoospermic patients. Semen samples of the treatment group were examined before and 1 month after acupuncture treatment by light microscopy and scanning electron microscopy. The matched control group was comprised of 20 untreated males, and two semen analyses were performed within a period of 2–4 months. A nonsignificant increase in the sperm count was found in three severely oligoteratoasthenozoospermic patients (from 0.7 ± 1.1 × 10⁶ to 4.3 ± 3.2 × 10⁶) 1 month after the acupuncture treatment. A significant increase in sperm count was found in ten (67%) out of the 15 azoospermic patients. In seven of these patients, the sperm count increased significantly from zero to an average of 1.5 ± 2.4 × 10⁶ (p ≤ 0.01), which could even be detected by light microscopy. Patients with genital tract inflammation also exhibited a significant increase in sperm count after treatment (from 0.3 ± 0.6 × 10⁶ to 3.3 ± 3.2 × 10⁶; p ≤ 0.02). Two pregnancies were achieved by IVF intracytoplasmic sperm injection following acupuncture treatment. This study concluded that acupuncture may have a beneficial effect for patients with very poor sperm density, especially those with genital tract inflammation.

A randomized controlled trial studying the effect of acupuncture plus clomiphene on 108 males with idiopathic normal gonadotrophic oligospermia (<20 million/ml) was reported by Xinyun [52]. In the acupuncture-plus-clomiphene group, acupuncture treatments with the addition of electrical stimulation or moxibustion to specific acupoints were administered every other day for 3 months. The control group received clomiphene only. The study revealed that a significantly higher percentage of achieved pregnancy or normalization of semen parameters was found in acupuncture and clomiphene combination therapy (74%) when compared with clomiphene monotherapy (52%).

In another prospective controlled study, Pei et al. randomized 40 subfertile men with idiopathic cause into acupuncture (n = 28) or untreated control groups (n = 12) [53]. Acupuncture treatments were administered twice a week for 5 weeks (25 min per session). Sperm morphology was quantitatively analyzed by transmission electron microscopy. The data showed a significant increase in the percentage and number of sperm without ultrastructural defects in the total ejaculates, specifically in the ultrastructural integrity of spermatozoa, after acupuncture.

Very recently, Dieterle et al. reported the first prospective randomized placebo-controlled study on the effect of acupuncture in subfertile males [54]. A total of 57 subfertile patients with severe oligoasthenozoospermia were randomly allocated into either acupuncture (n = 28) or placebo acupuncture groups (n = 29). Nonpenetrating placebo acupuncture needles were used in the placebo acupuncture group. Both acupuncture and placebo acupuncture treatments were applied for 45 min, twice a week for 6 weeks. The same acupoints were used as those in the Pei et al. study [53]. A significant increase in the percentage of total motile sperm was found after acupuncture treatment.

It is a usual practice in TCM to combine acupuncture and moxibustion in patients with specific syndrome differentiation in order to enhance the efficacy of acupuncture treatment. The use of both acupuncture and moxibustion in subfertile men has also been reported in previous studies [45,52].

Gerhard et al. investigated the effect of a 10-day course of acupuncture and moxibustion in 30 subfertile men [55]. The increase in the percentage of motile sperm was mild, but was significant from week 1 to 12 after completion of the whole course of treatment. The forward progressive motility increased from 21 to 26%, and the total motility increased from 42 to 50%. The maximal effect was detected 3 weeks after treatment, and this indicated that acupuncture may improve sperm maturation in the epididymis. Serum testosterone concentration increased significantly after treatment, and the increase was correlated with the improvements of sperm motility.

A total of 54 men with abnormal semen parameters, erectile dysfunction, ejaculatory dysfunction or azoospermia were treated with a combination of acupuncture and moxibustion [56]. Acupuncture was stated to be effective in cases of abnormal semen parameters (100%), ejaculatory dysfunction (86%) and erectile dysfunction (69%), but had no effect on azoospermia. However, effectiveness was neither quantified nor stratified according to specific semen parameters (density, motility or morphology). Pregnancy rates were also reported among those trying to conceive: 68% for men with abnormal semen parameters, 86% for men with ejaculatory dysfunction and 38% for men with erectile dysfunction.

Gurfinkel et al. randomized 19 men with semen abnormalities into study (n = 9) and control groups (n = 10) [57]. Patients in the study group received 25 min of classic acupuncture followed by 20 min of moxibustion twice a week for 10 weeks. Those in the control group received acupuncture and moxibustion at nontherapeutic indifferent points. Semen analysis was performed before and after treatment. This study revealed that the ratio of the normal form sperm increased significantly after classic acupuncture and moxibustion.

In addition to the traditional treatments of acupuncture and moxibustion, needling picking therapy, as well as a combined treatment of acupuncture, Chinese herbal medicine and acupoint injection, were also reported to have beneficial effect on semen quality, hormone profile and pregnancy rate [58,59].

Although the majority of the above studies suggested a positive effect of acupuncture on male subfertility, many studies are uncontrolled case series reports, the acupuncture protocol was not standardized and the sample sizes were not large enough to draw a definite conclusion. Therefore, randomized studies with adequate sample size are needed to provide evidence of the positive effect of acupuncture.

Management of sexual dysfunction

Although a Cochrane protocol of acupuncture for treating erectile dysfunction is available [60], the evidence is still too sparse to suggest that acupuncture is an effective intervention for treating erectile dysfunction [61]. In a case report, 73% of 100 patients with erectile dysfunction were able to have sexual intercourse at least once per week after a series of ten acupuncture plus moxibustion treatments [62]. Yaman et al. demonstrated a successful result, defined as having two or more satisfactory intercourses per week, in 69% of 29 patients with nonorganic erectile dysfunction after receiving a series of ten acupuncture treatments for 4 weeks [63].

Kho et al. conducted a pilot study in 16 men with erectile dysfunction [64]. Eight acupoints were used and low-frequency electrical stimulation was applied on four of the acupoints for 30 min, twice a week for 4 weeks. Acupuncture resulted in an improvement in the quality of erection in 15% of patients and 31% reported an increase in frequency of intercourse.

Aydin et al. recruited 60 patients with non-organic erectile dysfunction to assess the effectiveness of electro-acupuncture on sexual activity [65]. Patients were randomized into one of four groups: electro-acupuncture (n = 15), sham electro-acupuncture (n = 14), hypnosis (n = 16) and oral placebo (n = 15). In the electro-acupuncture group, five acupoints were selected and 3-Hz direct current was applied for 20 min, twice a week for 6 weeks. In the sham electro-acupuncture group, the same current and duration were applied on different acupoints. Hypnotic suggestions were given according to Crasilneck [66]. Vitamin pills were used in the oral placebo group. The improvement rate was 60% in the electro-acupuncture group, 75% in the hypnotic suggestion group, 43% in the sham electro-acupuncture group and 47% in the oral placebo group, but the differences among these groups were not significant.

Engelhardt et al. conducted another randomized placebo-controlled crossover trial among 21 patients with psychogenic erectile dysfunction [67]. Seven standardized acupoints were used in the treatment group, whereas three different acupoints that conventionally used to treat headache were applied in the placebo group. A total of five to 20 acupuncture treatments were administered with 20 min per session once or twice weekly. Ten nonresponders of the placebo group were crossed over to the treatment group. In the treatment group, 68.4% of patients achieved erection that was sufficient for penetration and sexual intercourse, and 21.1% of men reported that intercourse was possible when combined with an additional therapy. A significant increase was also found in the International Index of Erectile Function score in the domain of erectile function, intercourse satisfaction and overall satisfaction after the treatment.

A recent study demonstrated that acupuncture resulted in a decrease in scrotal skin temperature that correlated with an improvement in sperm count [68]. Another study demonstrated that needling ST-29 (Guilai) with 10-Hz electrical stimulation significantly increased testicular blood flow, which may have clinical benefit in treating male subfertility [69].

Management of primary dysmenorrhea

Dysmenorrhea, especially the severe type, affects the quality of life of many women. Acupuncture has been shown to be beneficial for patients with dysmenorrhea [70]. Eight studies comparing acupuncture with placebo acupuncture and other analgesia groups showed that the pain score was lower in the acupuncture group than that in other groups [71 –79]. Habek et al. recruited 57 women in a prospective, placebo-controlled trial to investigate the efficacy of acupuncture on primary dysmenorrhea [78]. Of these, 30 patients were treated with manual acupuncture together with auricular acupuncture in 3 consecutive days before the expected menstruation for 3 consecutive months. The remaining 27 patients received placebo acupuncture in which needles were inserted into other nonclassical acupoints superficially without eliciting any De Qi effect. The success rates of acupuncture 2 years after the acupuncture treatment were 93.3% in the acupuncture group and 3.7% in the placebo group.

Witt et al. investigated the effectiveness of acupuncture in patients with dysmenorrhea in a randomized controlled trial plus nonrandomized cohort study [79]. A total of 201 patients were randomly allocated to acupuncture (who received immediate acupuncture treatment for 3 months) or control groups (who received delayed acupuncture treatment after 3 months). Another 448 patients refused randomization, and immediate acupuncture treatments were provided for 3 months. A maximum of 15 acupuncture sessions were performed in randomized and nonrandomized acupuncture groups, but details of the acupuncture protocol were not given. Additional conventional treatments for pain relief were allowed if needed. It was demonstrated that the average pain intensity was significantly lower in the acupuncture compared with the control group (3.1 [95% CI: 2.7–3.6] vs 5.4 [95% CI: 4.9–5.9]; p < 0.001).

Six other studies demonstrated that there was no significant difference in the pain score between the treatment and control groups [80 –85]. Kempf et al. conducted a randomized double-blind placebo controlled trial to investigate the effect of laser needle acupuncture in women with dysmenorrhea [85]. A total of 18 patients were in the real laser acupuncture group and 30 patients were in the placebo laser acupuncture group (i.e., no laser activity). The same set of acupoints was applied in all patients. Eight sessions (20 min per session) were performed over a period of three menstrual cycles. It was found that no additional benefit of laser needle acupuncture was found when compared with placebo laser needle acupuncture.

Acupressure is defined as the stimulation of acupoints by means of pressure, usually using fingernails, seeds, toothpicks or blunt needles. Five studies reported that acupressure was better in pain relief when compared with placebo acupressure or conventional analgesic groups [86 –90]. By contrast, two studies reported no significant difference between acupressure and placebo acupressure, ibuprofen or Chinese herbal medicine [91,92].

Acupoint injection is a recent innovation of TCM, in which a small amount of a drug is injected at acupoints in order to enhance and prolong the effect of stimulation. The beneficial effect of acupoint injection in treating dysmenorrhea has also been reported [93]. The acupuncturist may supplement the acupuncture treatment with moxibustion. Several studies had reported its effect in women with dysmenorrheal [94 –102]. Five of them demonstrated that moxibustion could significantly reduce pain when compared with the conventional analgesic group [92 –96].

In a systematic review, Yang et al. concluded that there is no sufficient evidence to support the use of acupuncture-related therapies treatment on primary dysmenorrhea because of poor methodologic quality and small sample size [103]. Large-scale randomized controlled studies are needed for further confirmation.

Management of endometriosis

Endometriosis may be associated with chronic pelvic pain and is commonly found in patients with subfertility problems. In women with severe endometriosis, IVF is an effective treatment option for subfertility. The recurrence rate of chocolate cysts is high after laparoscopic ovarian cystectomy, and pharmacological treatments are associated with many side effects. Acupuncture has been used as an adjunct to alleviate some of its symptoms [104].

Although acupuncture is widely used in pain management, the analgesic effect of acupuncture in women with endometriosis-related pelvic pain has not been studied thoroughly. Highfield et al. presented two case reports describing the impact of a course of acupuncture on adolescent girls with endometriosis-related chronic pelvic pain [105]. One of the patients received individually tailored acupuncture treatments according to TCM syndrome differentiation theory twice-weekly for 7 weeks. Another patient received 15 sessions of acupuncture treatments over 12 weeks. Both patients experienced modest improvement in pain, as well as self- or family-reported improvement in premenstrual symptoms. No adverse effects were reported. The authors suggested that acupuncture may be an acceptable and safe adjunctive therapy for some adolescents with endometriosis-related pelvic pain.

Sun and Chen conducted a randomized controlled trial to investigate the therapeutic effects of acupuncture at Shu-Mu acupoints in women with endometriosis [106]. Patients were randomly allocated into one of the three groups: Shu-Mu point combination group, routine needling group and Western medicine group. It was demonstrated that the Shu-Mu point combination group was superior to other two groups in improvement of endometriosis-related symptoms, such as dysmenorrhea and irregular menstruation. Serum CA125 in the Shu-Mu point combination group significantly decreased after treatment.

Schnyer et al. developed a Japanese-style acupuncture protocol for women with endometriosis-related pelvic pain [107]. This is a kind of flexible, dynamic, individually tailored treatment, as in routine clinical practice, which simultaneously assures replicability, consistency and standardization. It consisted of four board steps:

Treatment of the divergent channels based on electrical impedance findings at jingwell points;

Treatment of the extraordinary vessels and other extra channel polarizations based on abdominal conformation and electrical impedance findings;

Treatment of auricular points;

Treatment of the symptom by selecting local points.

In contrast to TCM-style acupuncture, shallow and light needling stimulation using more fine needles without vigorous manipulation were applied.

The same group applied this method of individually tailored acupuncture treatments in a randomized sham-controlled trial to assess its effect on reducing chronic pelvic pain and improving quality of life in young women with endometriosis [108]. A total of 14 patients were randomized into either active acupuncture group (n = 9) or sham acupuncture group (n = 5). In this study, the Streitberger sham acupuncture device was used in the control group. A total of 16 acupuncture sessions were performed, twice weekly for 8 consecutive weeks. The pain scale was significantly reduced after 4 weeks of treatments in the active acupuncture group (average reduction point: 4.8) than that in the sham acupuncture group (average reduction point: 1.4). There was no significant difference in improvement in quality of life when compared between groups. Japanesestyle acupuncture may be an effective, safe and well-tolerated adjunct therapy for women with endometriosis-related pelvic pain.

In a randomized trial, Jin et al. compared the therapeutic effect of auricular electro-acupuncture (AEA) with body electro-acupuncture (BEA) on endometriosis-related dysmenorrhea [109]. All treatments were performed 30 min per session, once every other day for 3 months. Dysmenorrhea severity score (DSS) significantly decreased during the first two menstrual cycles in BEA and during three consecutive menstrual cycles in AEA. There was no significant difference in clinical therapeutic effect between two groups (p > 0.05). This study concluded that the analgesic effect of AEA on endometriosis-induced dysmenorrhea was superior to BEA.

However, the sample sizes of all the aforementioned studies are small, and different acupuncture protocols were used. Thus, it is difficult to draw a firm conclusion about the effect of acupuncture on endometriosis. Larger prospective, randomized controlled trials are warranted.

Management of menopausal symptoms

Hot flash is a significant common problem in menopausal women and can be quite troublesome. Hormone replacement therapy has been the standard choice for reducing hot flashes, but it is associated with risks such as breast cancer, coronary heart disease and strokes. Acupuncture has been tried to relieve menopausal symptoms.

Huang et al. recruited 29 postmenopausal women with hot flashes and evaluated the effect of acupuncture on nocturnal hot flashes and sleep quality in a randomized placebo controlled manner [110]. Of these, 12 patients received active acupuncture treatments, whereas 17 patients received placebo acupuncture treatments (sham points with placebo needle). Nine sessions of treatment were administrated over 7 weeks. Each session was 20 min long, and acupuncturists used a standardized algorithm to determine point prescription. It was shown that acupuncture significantly reduced the severity of nocturnal hot flashes compared with placebo acupuncture, but did not influence sleep.

Vincent et al. conducted a randomized singleblind sham-controlled trial on the effect of acupuncture in peri- and post-menopausal women with hot flashes [111]. A total of 103 patients were randomized to medical or sham acupuncture. Treatments were administered twice a week for 5 weeks, and each session lasted for 30 min. In the medical acupuncture group, 12 acupoints were preselected and used, whereas nonacupoints (5 cm or more away from the actual acupoint) were used in the sham acupuncture group. There was no significant difference in reducing hot flashes between two groups.

Avis et al. also compared the effect of acupuncture in peri- and post-menopausal women with hot flashes with usual care and sham acupuncture in a randomized controlled pilot trial [112]. Acupuncture treatments were scheduled twice a week for 8 consecutive weeks. Shallow needling in nontherapeutic sites was used in the sham acupuncture group. Four sets of acupoints were preselected and were used based on the TCM diagnosis. There was no significant difference in the reduction of frequency of hot flashes between two groups, although a significant decrease in frequency of hot flashes was detected between weeks 1 and 8 among all groups.

In a multicenter, large-scale randomized controlled trial, Borud et al. randomized 267 menopausal women experiencing hot flashes into acupuncture and control groups [113]. Ten sessions of acupuncture treatment and self-care advice were given in acupuncture group, and acupuncture treatment was individualized for each patient according to TCM diagnosis. The control group received self-care advice only. There was a significant reduction in the frequency and intensity of hot flashes, as well as an improvement in health-related quality of life in the acupuncture group when compared with the control group. The significant differences between two groups found at the treatment period were no longer present at 6 and 12 months during the follow-up period [114]. It suggested that acupuncture has no long-term effects on hot flashes among menopausal women.

Kim et al. conducted another similar multicenter, randomized controlled trial in Korea, where 175 peri- and post-menopausal women with hot flashes were randomly allocated to acupuncture or control groups [115]. In this study, six standardized acupoints were used in the acupuncture group, and 12 sessions of acupuncture were given over 4 weeks. The control group received usual care only. The reduction in the average 24-h hot flash score was significantly greater in the acupuncture group than in the control group. Greater improvements in menopause-related symptoms were also found in the acupuncture group.

Recently, some studies also investigated the effect of moxibustion and laser acupuncture in menopausal hot flashes [116,117], but only moxibustion showed a significant improvement in menopausal symptoms [116].

Two systematic reviews concluded that there is no consensus on the effect of acupuncture in relieving menopausal hot flashes due to poor methodologic quality and small sample size in previous published study [118,119]. More well-designed controlled trials are therefore warranted.

Future perspective

Acupuncture may have a role in pain relief during oocyte retrieval, improving IVF outcomes and management of male factors, primary dysmenorrhea, endometriosis-related chronic pelvic pain and menopausal symptoms. However, most studies reviewed here are of poor methodological quality. The number of controlled trials remains small and the sample size of many studies is underpowered. In addition, information on the randomization process, allocation concealment and blinding of assessors are not usually mentioned.

Besides methodological limitations, the acupuncture protocol also varied among studies; for example, time of treatment commencement, total dosage of the treatment, number of needles used, needle gauge, acupoints used, stimulation method and treatment provider. Some studies adopted a standardized treatment protocol, whereas others used individualized treatment protocols according to the TCM theory. The choice of the controls also varied among the studies, and the best control for double-blind studies remains unknown.

Acupuncture is a safe treatment when performed by a certified acupuncturist under good-practice guidelines of sterilization. Several systematic reviews and large prospective studies revealed the common potential side effects of acupuncture were needle pain, tiredness and bleeding [120 –122]. Incidence of faintness and syncope, serious adverse effects such as trauma to internal organs and infection were uncommon [123]. No severe side effects were reported in all previously mentioned studies.

Further studies should attempt to explore other potential placebos, evaluating the efficacy and cost–effectiveness of acupuncture by conducting a well-designed, high-quality randomized controlled trial and investigating the underlying mechanism of acupuncture treatment.

Executive summary

Pain relief for oocyte retrieval

Acupuncture can be considered as an alternative therapy for pain relief during oocyte retrieval in patients who cannot tolerate conventional conscious sedation because of its associated systemic adverse effects.

Improving IVF outcomes

Six meta-analyses have been published on the role of acupuncture in IVF treatment, but there is still no consensus on the improvement of pregnancy outcomes following acupuncture administered on the day of embryo transfer.

Management of anovulatory subfertility

There is a lack of randomized controlled studies in the treatment of ovulation disorders.

Management of male subfertility & sexual dysfunction

Acupuncture and moxibustion may improve sperm quality, especially sperm morphology, and erectile dysfunction. More well-designed studies with adequate sample size are needed.

Management of primary dysmenorrhea

Dysmenorrhea can be improved by acupuncture, auricular acupuncture, self-acupressure, moxibustion and acupoint injection.

Management of endometriosis

Acupuncture may be used as an adjunct to alleviate endometriosis-related chronic pelvic pain.

Management of menopausal symptoms

Acupuncture and moxibustion may improve menopausal symptoms. Further exploration is merited.

Footnotes

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

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Acupuncture in Reproductive Medicine

Abstract

Keywords

Pain relief for oocyte retrieval

Improving IVF outcomes

Management of anovulatory subfertility

Management of male subfertility

Management of sexual dysfunction

Management of primary dysmenorrhea

Management of endometriosis

Management of menopausal symptoms

Future perspective

Footnotes

References