Acupuncture for IVF – 8 Key Ideas Worth Thinking Through If You Are Preparing for IVF!

Acupuncture For IVF – This Is Why!

Acupuncture treatments should preferably begin 3 months leading up to embryo transfer because ovarian follicles go through a 90-120 day development period before they mature for ovulation.

These treatments possibly increase ovarian response to IVF medications by increasing blood flow to the uterine lining and the ovaries. The treatments also relieve the effects of stress and anxiety.

Acupuncture increases blood flow to the ovaries

A 2005 randomized trial was carried out in the IVF center of China Medical University Hospital in Taiwan found that electroacupuncture reduces uterine artery blood flow impedance in women. When blood circulation is improved, the uterus is better nourished, making it a more ideal environment for implantation.

Increasing blood circulation to the ovaries and uterus, can in turn improve the quality of the follicular fluids that nourish the developing eggs.

Acupuncture reduces stress and nervous system overwhlem

In a 2009 paper published in Fertility and Sterility, women going through IVF were given acupuncture to increase blood flow through the uterine arteries in the immediate weeks before egg collection. The researchers found that the women who had acupuncture showed beneficial changes in serum levels of stress hormones compared to the control group of women who did not have acupuncture.

The acupuncture treatments appeared to have normalized levels of cortisol and prolactin which had been artificially depressed by the IVF drugs. This may have implications for both egg quality and implantation. In addition the pregnancy and live birth rate was significantly higher in the acupuncture group.

Stress is one of the main contributing factor towards infertility in modern women. It puts us into a “defense” mode by sending a message from the hypothalamus to the pituitary gland that starts the ‘flight or fight’ response.

This response activates our adrenal glands to produce adrenaline, cortisol and DHEA (dehydroepiandrosterone) which interferes with the overall balance of hormones. This can have a profound effect if you are trying to conceive.

Scientists found that those with high levels of stress hormone stop ovulating and are therefore unable to conceive. This is why it is common enough that when you go for a business trip or are having a stressful week, ovulation is actually delayed until you settle back into a less stressful routine.

Acupuncture has been known to help reduce stress levels and keep the hormones in check for natural ovulation to occur. When the body and mind are relaxed, the endocrine system can resume its work unobstructed.

Acupuncture regulates hormonal imbalance

Stener-Victorin (2011 & 2013) demonstrated that delayed cycles are shortened with regular acupuncture sessions. Another small prospective trial published in the American Journal of Physiology, followed 32 women with PCOS for around 3 months. Acupuncture, say the researchers, has been demonstrated to improve menstrual frequency and to decrease circulating testosterone in women with PCOS.

It is widely accepted that that acupuncture normalizes ovulatory function by regulating hormones (Chen, 1997). This was earlier demonstrated in a study where 6 out of 13 anovulatory cases responded to acupuncture treatment (Chen and Yu, 1991).

There was also one pilot study of acupuncture as a substitute for hCG to induce ovulation (Cai, 1997). Of the 11 menstrual cycles, marked effect was shown in 5 cycles, significant effect in 5 cycles but no effect in 1 cycle.

HPO axis dysfunction is one reason why women have delayed menses even to the point of bleeding only once every few months. Stener-Victorin’s study in 2008 demonstrated that acupuncture is able to modulate central beta-endorphin production and secretion, which then regulate secretion of GnRH and gonadotropins like LH and FSH,

It is clear that acupuncture is able to regulate ovulatory function and balance out your hormones.

While time is of essence for many women in their 30s, there are benefits to preparing the womb ahead of time too. It is recommended that you start coming in for regular treatments at least 2-3 months prior to the next IVF cycle.

Reference:

1. Ho M, Huang LC, Chang YY, Chen HY, Chang WC, Yang TC, Tsai HD. Electroacupuncture reduces uterine artery blood flow impedance in infertile women. Taiwan J Obstet Gynecol. 2009 Jun;48(2):148-51.
2. Magarelli PC, Cridennda DK, Cohen M. Changes in serum cortisol and prolactin associated with acupuncture during controlled ovarian hyperstimulation in women undergoing in vitro fertilization-embryo transfer treatment. Fertil Steril. 2009 Dec;92(6):1870-9.
3. Lin JH, Liu SH, Chan WW, Wu LS, Pi WP, “Effects of electroacupuncture and GnRH treatments on hormone changes in anoestrous sows,” Am J Chin Med 1988; 16: 117-26.
4. Yang SP, Yu J, He L, “Release of GnRH from the medio-basal hypothalamus induced by electroacupuncture in conscious female rabbits,” Acupunct Electrother Res 1994; 19: 19-27.
5. Aso T, Motohashi T, Murata M, Nishimura T, Kakizaki K, “The influence of acupuncture stimulation on plasma levels of LH, FSH, P and E2 in normally ovulating women,” Am J Chin Med 1976;4:391-401.
6. Yu J, Zheng HM, Ping SM, “Changes in serum FSH, LH and ovarian follicular growth during electroacupuncture for induction of ovulation,” Chung Hsi I Chieh Ho Tsa Chih 1989;9:199-202.
7. Mo X, Li D, Pu Y, Xi G, Le X, Fu Z, “Clinical studies on the mechanism of acupuncture stimulation of ovulation,” J Trad Chin Med 1993;13:115-9.
8. Stener-Victorin et al, “Acupuncture in polycystic ovary syndrome: current experimental and clinical evidence,” J Neuroendocrinol 2008 Mar;20(3):290-8.
9. Chen. (1997) Acupuncture Normalizies Dysfunction of Hypothalamic-Pituitary-Ovarian Axis. Acupuncture & Electro-Therapeutics Research, Volume 22, Number 2, 97-108(12).

Acupuncture For IVF – What Has Age Gotta Do With It?

Several studies had been done to understand the affects of acupuncture on different age group of women undergoing IVF.

Study One: Older Women may benefit more from Acupuncture

A recent study by Nick Dalton Brewer in 2010 found that women aged 35 to 39 years and those over 40 years achieved higher pregnancy rates than those who did not receive acupuncture treatment. In this particular study, 71 patients underwent acupuncture before and after embryo transfer. Overall, positive pregnancy rates were 44.6% comparing favorably with the non-acupuncture historic control group.

When analyzed in greater detail, by maternal age at the time of treatment, biochemical pregnancy results for acupuncture-treated women was 52% (less than 35 years old), 45% (35-39 years old) and 35% (40-45 years old). While it is clear that the younger women got better results, that is insightful is this: for the older subgroup, those using acupuncture had better results than the controls.

This suggests that acupuncture intervention may be more effective the older the woman is!

Study Two: Lower Rate of Pregnancy Loss from using Acupuncture

Back in 2008, David Youran did a similar study with regards to acupuncture and IVF, whereby the subjects were subdivided by age. Those under 35 years old showed the greatest benefit from acupuncture, a 63.3% chemical pregnancy rate to 43.2% in the non-acupuncture group.

Combining all the age groups, the cycle parameters between the two groups (above 35 and under 35 years old) were equivalent, while pregnancy rate was higher. The good news was that the loss rate was lower for the acupuncture group: 6% vs. 30.4%.

The above studies are encouraging and suggest that acupuncture pre- and post-ET can be beneficial for older women looking to conceive. Acupuncture appears to help with age-related infertility. Acupuncture may also be useful to treat diminished ovarian reserve. All this could be related to how acupuncture helps with blood flow in the reproductive organs while reducing stress levels.

References:

1. Nick Dalton-Brewer, “Increasing IVF Success with Acupuncture”
2. D.B. Youran, B.L. Bopp, R.M. Colver, L.M. Reuter, G.K. Adaniya, “Acupuncture performed before and after embryo transfer improves pregnancy rates”

Acupuncture After Embryo Transfer – When Should We Do It?

Background

In 2006, Westergaard and colleagues conducted a study evaluating the effect of acupuncture in patients undergoing IVF/ICSI. One group receive acupuncture on the day of ET (group ‘Acu1’); another group on the day of ET and also 2 days later (group ‘Acu2’). Both groups were compared with a control group that did not receive any acupuncture treatment.

Like many others, Westergaard chose to follow the acupuncture points mentioned in Paulus et al (2002). Acupuncture was performed immediately before and after ET for both groups, with each session lasting 25 minutes. For group Acu2, another 25 minutes session was performed 2 days later using a completely different set of acupoints. These points were chosen to reduce sympathetic activation, and also to improve of uterine blood perfusion, so as to enhance endometrial receptivity for implantation.

Overall, clinical pregnancy and live birth rates were higher in group Acu1 than the two other groups. This study showed how acupuncture during the day of ET helps improve the reproductive outcomes of IVF/ICSI. That said, it is worth noting that repeating acupuncture 2 days later had no additional benefit.

In fact, the group that received acupuncture 2 days after ET had a miscarriage rate of 33%. This is higher than the 21% miscarriage rate in the group that had acupuncture only on the day of ET, or the 15% in the control group. Statistical analysis showed that these results might still have occurred by random chance.

Analysis

1. Timing of Implantation

Westergaard wanted acupuncture exactly 2 days later because implantation of the embryos into the uterine lining does not occur for two to five days after ET depending on when the embryos were transferred. It is unknown whether the effect of acupuncture performed on the day of ET would last until the day of embryo implantation or longer.

The timing of implantation is different for different women — as acupuncture has been shown to cause contraction in the uterus, any stimulation two days after ET might be disruptive for some women. Furthermore, building up a thick healthy endometrium for implantation does not occur within a day but is more likely the outcome of routine and consistent acupuncture done weeks before the start of the IVF cycle.

2. Choice of Points

Also, the acupoints mentioned might not have been suitable for post-ET treatment. We do notice that the lower abdomen was clearly avoided but points LI4 and SP6 are a point-pair that is contraindicated during pregnancy. These points are often used to stimulate labor and can cause uterine contraction. Historical wisdom should not be neglected and this pair may not be suitable during the implantation window.

3. Training and Consistency in Needling

Lastly, the nurses conducting the acupuncture sessions were briefly trained just for the purpose of this study, each performing between 2 to 24 acupuncture sessions. Westergaard did mention that the needles were stimulated to maintain deqi sensation for every session. This could be a partial contributing factor for the discrepancy in the outcomes as well.

Our Interpretation

Our understanding is that this study leans towards using a Paulus-type protocol only on the day of embryo transfer, and using a separate “implantation” protocol 2 days post-transfer. Same day post-ET treatment is often not so convenient, and if not implementable, we suggest that you rest after the procedure and come back for an “implantation” protocol about 4-7 days after ET.

Acupuncture For IVF – What Does It Do For Ovarian Hyperstimulation Syndrome (OHSS)?

Ovarian hyperstimulation syndrome affects women taking hormone medications such as human chorionic gonadotrophin (hCG) and human menopausal gonadotrophin (hmG) to stimulate the development of eggs in the ovaries. This may occur in women undergoing in vitro fertilization (IVF), ovulation induction or intrauterine insemination.

The use of such hormones in your system may lead to ovarian hyperstimulation, in which your ovaries become swollen and painful. A small number of women may develop severe OHSS, which can cause rapid weight gain, abdominal pain, vomiting and shortness of breath.

Ovarian hyperstimulation syndrome is a serious complication to expect during the IVF cycle. Any patient undergoing artificial induction of ovulation is at risk of developing OHSS, although some are more at risk than others. The symptoms usually begin four to five days after the egg collection.

While up to 33% of women experience the mild forms of OHSS, 3-8% has reported severe OHSS. Despite significant advances in assisted reproductive technology over the years, there are always at-risk responders.

Acupuncture can help eliminate the symptoms of mild OHSS or relieve the discomfort in the severe cases. According to a study done by Nanjing Medical University in 2016, it concluded that electroacupuncture may provide a simple and effective method for the prevention and treatment of OHSS.

The results indicate that electroacupuncture can modulate endocrine hormone secretion and affect the secretion of inflammatory cytokines and vascular endothelial growth factor, and thus prevent the progress of OHSS.

In another study conducted in 2014, 53 out of 109 women undergoing IVF/ICSI were assigned to electroacupuncture during the cycle. Compared with the non-acupuncture group, the occurrence of OHSS and the canceling rate of transplant cycles were significantly lower in the acupuncture group.

Acupuncture is usually recommended after egg collection to help recovery from anesthetic, local tissue trauma, and most importantly, the prevention of OHSS. The timing and number of acupuncture treatments will vary between women and their individual conditions to best support their recovery before embryo transfer.

References:

1. Hong YL, Tan Y, Yin YY, Zou YJ, Guo YH, Nie XW. Effect of electro-acupuncture on clinical outcomes and ovarian hyperstimulation syndrome in in vitro fertilization and embryo transplantation. Zhongguo Zhong Xi Yi Jie He Za Zhi. 2014 Nov;34(11):1292-6.
2. Chen L, Sun HX, Xia YB, Sui LC, Zhou J, Huang X, Zhou JW, Shao YD, Shen T, Sun Q, Liang YJ, Yao B. Electroacupuncture decreases the progression of ovarian hyperstimulation syndrome in a rat model. Reprod Biomed Online. 2016 May;32(5):538-44.

Acupuncture for IVF – Is Sham Acupuncture Really Inert?

Multiple studies had been done by Stener-Victorin showing an increase in ovarian blood flow (OBF) in both humans and animals as a result of acupuncture. Pulsatility Index (PI) was used as a measure of blood flow resistance in the uterine arteries and according to Chiang et al in 2000, the higher the PI, the lower the pregnancy rate.

In order to bring down the PI level, Stener-Victorin tested the efficacy of acupuncture and found that blood flow impedance was reduced after 4 consecutive weeks of twice-weekly acupuncture sessions. 10 infertile but otherwise healthy women with a PI of more than 3.0 achieved a PI of less than 0.0001 after the eighth electroacupuncture session.

When experimented on anaesthetized rats, low frequency electroacupuncture significantly lowered OBF. These OBF measurements were tracked using ultrasound doppler flow meter on the surface of the left ovary. In other words, it may be that acupuncture could increase pregnancy rate by increasing blood flow in the uterine arteries. The response appears to be mediated by the ovarian sympathetic nerves as a reflex response.

Acupuncture may help to modulate sympathetic outflow to the ovaries. Again in 2003, Stener-victorin’s study established that ovarian concentrations of vasoconstrictor ET-1 were significantly lower in the PCO group receiving acupuncture as opposed to the healthy control group.

The results indicate that EA modulates the neuroendocrinological state of the ovaries, most likely by modulating the sympathetic nerve activity in the ovaries, which may be a factor in the maintenance of steroid-induced PCO.

References:

1. E. Stener-Victorin, T. Lundeberg, S. Cajander et al., “Steroid-induced polycystic ovaries in rats: effect of electro-acupuncture on concentrations of endothelin-1 and nerve growth factor (NGF), and expression of NGF mRNA in the ovaries, the adrenal glands, and the central nervous system,” Reproductive Biology and Endocrinology, vol. 1, article 33, 2003.
2. Stener-Victorin, Waldenstrom, Andersson, Wikland, “Reduction of blood flow impedance in the uterine arteries of infertile women with electro-acupuncture,” Hum Reprod. 1996 Jun;11(6):1314-7.
   Chiang CH, Hsieh TT, Chang MY, Shiau CS, Hou HC, Hsu JJ, et al, “Prediction of pregnancy rate of in vitro fertilization and embryo transfer in women aged 40 and over with basal uterine artery pulsatility index,” J Assist Reprod Genet 2000; 17:409-14.
3. Stener-Victorin E, Kobayashi R, Kurosawa M, “Ovarian blood flow responses to electro-acupuncture stimulation at different frequencies and intensities in anaesthetized rats,” Auton Neurosci. 2003 Oct 31;108(1-2):50-6.
4. Stener-Victorin E, Fujisawa S, Kurosawa M., “Ovarian blood flow responses to electroacupuncture stimulation depend on estrous cycle and on site and frequency of stimulation in anesthetized rats,” J Appl Physiol (1985). 2006 Jul;101(1):84-91.

Acupuncture Post-Embryo Transfer: When Should We Do It?

In Singapore, more couples are resorting to IVF to conceive. According to preliminary figures from the Ministry of Health (MOH), 6059 assisted reproduction cycles were carried out last year, 549 more than in 2013 and 1099 more than the year before. Amongst these couples, success rate of IVF treatment ranged from 16% to 28% across all private and public institutions in Singapore.

Many couples and doctors are looking into ways to increase the chances of a live birth. One popular approach that is popular across the States and Europe is to integrate Traditional Chinese medicine throughout the IVF process.

Acupuncture is commonly administered in conjunction with embryo transfer due to its significant effectiveness in improving pregnancy rates and helping the women stay relax throughout the procedure.

According to the Westergaard study published in Fertility and Sterility in 2006, acupuncture on the day of embryo transfer significantly improves the reproductive outcome of IVF/ICSI, compared with no acupuncture. This paper recommends that acupuncture is done 20 minutes prior and after the embryo transfer or at best, on the day itself.

The treatment is based off the 2002 German Protocol whereby a series of two acupuncture treatments are performed on the day of IVF transfer. The treatments are scheduled before and after the embryo transfer on the same day. This study has been published and replicated multiple times over the years.

In the study of 160 participants, one group received IVF transfer only while the second group received IVF transfer with two acupuncture treatments (before and after transfer). The pregnancy results showed 42% in the acupuncture group compared to 26% in the control group. Acupuncture points are selected to help move blood towards the uterus while relaxing the body and mind for the implantation to take place as instinctively as possible.

Background

In 2006, Westergaard and colleagues conducted a study evaluating the effect of acupuncture in patients undergoing IVF/ICSI. One group receive acupuncture on the day of ET (group ‘Acu1’); another group on the day of ET and also 2 days later (group ‘Acu2’). Both groups were compared with a control group that did not receive any acupuncture treatment.

Like many others, Westergaard chose to follow the acupuncture points by Paulus et al (2002). In this German Protocol, acupuncture was performed immediately before and after ET for both groups, with each session lasting 25 minutes.

For group Acu2, another 25 minutes session was performed 2 days later using a completely different set of acupoints. These points were chosen to reduce sympathetic activation, and also to improve of uterine blood perfusion, so as to enhance endometrial receptivity for implantation.

Overall, clinical pregnancy and live birth rates were higher in group Acu1 than the two other groups. This study showed how acupuncture during the day of ET helps improve the reproductive outcomes of IVF/ICSI.

That said, it is worth noting that repeating acupuncture 2 days later had no additional benefit. In fact, the group that received acupuncture 2 days after ET had a miscarriage rate of 33%. This is higher than the 21% miscarriage rate in the group that had acupuncture only on the day of ET, or the 15% in the control group. Statistical analysis showed that these results might still have occurred by random chance.

Analysis

1. Timing of Implantation

Westergaard wanted acupuncture exactly 2 days later because implantation of the embryos into the uterine lining does not occur for two to five days after ET depending on when the embryos were transferred. It is unknown whether the effect of acupuncture performed on the day of ET would last until the day of embryo implantation or longer.

The timing of implantation is different for different women — as acupuncture has been shown to cause contraction in the uterus, any stimulation two days after ET might be disruptive for some women. Furthermore, building up a thick healthy endometrium for implantation does not occur within a day but is more likely the outcome of routine and consistent acupuncture done weeks before the start of the IVF cycle.

2. Choice of Points

Also, the acupoints mentioned might not have been suitable for post-ET treatment. We do notice that the lower abdomen was clearly avoided but points LI4 and SP6 are a point-pair that is contraindicated during pregnancy. These points are often used to stimulate labor and can cause uterine contraction. Historical wisdom should not be neglected and this pair may not be suitable during the implantation window.

3. Training and Consistency in Needling

Lastly, the nurses conducting the acupuncture sessions were briefly trained just for the purpose of this study, each performing between 2 to 24 acupuncture sessions. Westergaard did mention that the needles were stimulated to maintain deqi sensation for every session. This could be a partial contributing factor for the discrepancy in the outcomes as well.

Our Interpretation

Our understanding is that this study leans towards using a Paulus-type protocol only on the day of embryo transfer, and using a separate “implantation” protocol 2 days post-transfer. Same day post-ET treatment is often not so convenient, and if not implementable, we suggest that you rest after the procedure and come back for an “implantation” protocol about 4-7 days after ET.

Acupuncture for IVF: Endometrial Receptivity in Women undergoing FET

In this first ever study (2015) to evaluate the effect of acupuncture on endometrial receptivity in women undergoing Frozen Embryo Transfer, results indicate significant effect in producing higher rates of embryo implantation, clinical pregnancy and live birth following IVF/ART.

Shuai et al ran a single-blind, prospective randomised controlled trial with a total of 68 women undergoing frozen embryo transfer (FET). A higher frequency of the ultrasonographic triple-line endometrial pattern, greater endometrial/subendometrial VI and increased HOXA10 protein expression were noted in the acupuncture group in the present study.

Women with a regular menstrual cycle could be offered electro-acupuncture in the 3 months prior to FET as acupuncture appears to enhance endometrial receptivity. Further research is required to confirm the apparent benefits of acupuncture in women undergoing FET, ideally in the form of large-scale multicentre clinical trials.

Source: Zhenhong Shuai, Fang Lian, Pengfei Li, Wenxiu Yang. Effect of transcutaneous electrical acupuncture point stimulation on endometrial receptivity in women undergoing frozen-thawed embryo transfer: a single-blind prospective randomised controlled trial. Acupunct Med 2015;33:9–15.

Acupuncture for IVF – Surviving The Two Week Wait (2ww)

Are women’s stress levels associated with infertility? A group of researchers in U.S. decided to look into this. They measured biomarkers from specific chemicals and hormones using their saliva and performed a perceived stress questionnaire with almost 400 couples. What they found was that when these biomarkers and perceived stress scores were higher, the time to pregnancy was also increased.

The two weeks after embryo transfer can be a strenuous game for some women. The excitement can turn into anxiety which can overload the body and bring on the adverse result.

Considering the financial cost of IVF treatment, the intense longing for a baby and the all-too-stressful waiting game, many women are under much strain during the two week wait, thinking that nothing can be done in the mean time.

Acupuncture can be incorporated at this time to ease the mind and help the hopeful mother to sleep better at night. In a series of studies at Georgetown University Medical Center (GUMC), researchers are demonstrating how acupuncture can significantly reduce the stress hormone response in an animal model of chronic stress.

Dr Eshkevari, a physiologist, designed a series of studies in rats to test the effect of electronic acupuncture on levels of proteins and hormones secreted by biologic pathways involved in stress response. They found that electronic acupuncture blocks the chronic, stress-induced elevations of the HPA axis hormones and the sympathetic NPY pathway.

Acupuncture works by facilitating the release of pain-killing endorphins that help relieve feelings of anxiety and depression and bring balance in the body. During the two-week wait, acupuncture can be used to manage any side effects you might experience such as moodiness, abdomen swelling, fatigue, muscle tension and anxiety.

Our treatment protocols are based on your symptoms and needs, we encourage dropping by once or twice during the two week period.

References:

1. C.D. Lynch, R. Sundaram, J.M. Maisog, A.M. Sweeney, and G.M. Buck Louis. Preconception stress increases the risk of infertility: results from a couple-based prospective cohort study—the LIFE study. Acta Obstet Gynecol Scand. 2000 Feb;79(2):113-8.Hum Reprod. 2014 May; 29(5): 1067–1075.
2. Eshkevari L, Permaul E, Mulroney SE. Acupuncture blocks cold stress-induced increases in the hypothalamus-pituitary-adrenal axis in the rat. J Endocrinol. 2013 Mar 15;217(1):95-104.

If you find all this information useful, do read about reference to our clinic in Vogue Magazine.

All the above information is useful to know if you are undergoing assisted therapies like IVF and IUI. It is also useful knowledge if you are attempting a natural cycle without assisted therapies.

At our clinic, we treat patients coming in for Preconception, Pregnancy as well as Postpartum using Chinese Medicine as well as other treatment modalities. Contact us if you want to find out more!