Role of acupuncture in the treatment of female infertility
Raymond Chang, M.D.[a,b] Pak H. Chung, M.D.[b] and Zev
Rosenwaks, M.D.[c]
The Institute of East-West Medicine and the Center for
Reproductive Medicine and Infertility, Weill Medical College
of Cornell University, New York, New York
Received June 24, 2002; revised and accepted July 19, 2002.
Reprint requests: Pak H. Chung, M.D., The Center for Reproductive
Medicine and Infertility, Weill Medical College of Cornell
University, 505 East 70 Street, New York, New York 10021
(FAX: 212-746-8208; E-mail: pakchu@med.cornell.edu).
[a]The Institute of East-West Medicine. [b]The Department
of Internal Medicine, Weill Medical College of Cornell Unversity.
[c]The Center for Reproductive Medicine and Infertility.
0015-0282/02/$22.00
PII S0015-0282(02)04348-0
Objective: To review existing scientific rationale
and clinical data in the utilization of acupuncture in the
treatment of female infertility.
Design: A MEDLINE computer search was performed
to identify relevant articles.
Result(s): Although the understanding of acupuncture
is based on ancient medical theory, studies have suggested
that certain effects of acupuncture are mediated through
endogenous opioid peptides in the central nervous system,
particularly ß-endorphin. Because these neuropeptides
influence gonadotropin secretion through their action on
GnRH, it is logical to hypothesize that acupuncture may
impact on the menstrual cycle through these neuropeptides.
Although studies of adequate design, sample size, and appropriate
control on the use of acupuncture on ovulation induction
are lacking, there is only one prospective randomized controlled
study examining the efficacy of acupuncture in patients
undergoing IVF. Besides its central effect, the sympathoinhibitory
effects of acupuncture may impact on uterine blood flow.
Conclusion(s): Although the definitive role of acupuncture
in the treatment of female infertility is yet to be established,
its potential impact centrally on the hypothalamic-pituitary-ovarian
axis and peripherally on the uterus needs to be systemically
examined. Prospective randomized controlled studies are
needed to evaluate the efficacy of acupuncture in the female
fertility treatment. (Fertil Steril® 2002;78:1149-53.
©2002 by American Society for Reproductive Medicine.
Key Words: Acupuncture, female infertility, in vitro
fertilization
Acupuncture as a therapeutic intervention has been extensively
studied and is increasingly practiced in the United States.
A recent survey of acupuncture released by an NIH Consensus
Development panel (1) indicated that although there are
inherent problems of design, sample size, and appropriate
controls in the acupuncture literature, promising data exist
for the use of acupuncture in treating nausea and vomiting
(2), postoperative pain (3-5), addiction (6-9), and general
pain syndromes (10-12). As a medical technique, acupuncture
has also been reported as an adjunct in the treatment of
various gynecologic problems (13-15).
Although conventional treatment options for female infertility
have been well established, there have been few systematic
reviews of complementary or alternative approaches to the
treatment of infertility. In light of an increasing trend
in the use of complementary and alternative medicine (16)
and common inquiry and utilization of such approaches by
patients suffering from infertility, we intend to review
the existing scientific rationale and clinical data based
on which acupuncture may exert an influence on the outcome
of female fertility.
In examining the potential usefulness of acupuncture in
enhancing female fertility, it is appropriate first to give
some theoretical background for acupuncture. Although the
theory of acupuncture stems from underlying traditional
Chinese medicine premises that would define etiologies for
infertility in terms of energy disturbance of imbalances,
or organ deficiencies and excesses, we intend to review
the existing literature by examining modern medical aspects
of the central and peripheral modes of action of acupuncture
as they impact on the hypothalamic-pituitary-ovarian axis
and the pelvic organs, respectively. Moreover, the effect
of acupuncture on anxiety and stress and ensuing potential
indirect effects on female fertility will also be discussed.
Background
Acupuncture is the manipulation of thin metallic needles
inserted into anatomically defined locations on the body
to affect bodily function. The US Food and Drug Administration
has recently removed acupuncture needles from the category
of experimental medical devices and now regulates them just
like it does other devices, such as surgical scalpels and
hypodermic needles, under good manufacturing practices and
single-use standard of sterility (1).
The general theory of acupuncture is based on the premise
that there are patterns of energy flow (Qi) through the
body, which are essential for health. Disruption of this
flow is believed to be responsible for disease. Acupuncture
can correct imbalances of flow at identifiable points close
to the skin.
According to the proposed international acupuncture nomenclature
by The World Health Organization in 1991 (17), the meridian
system consists of 20 meridians interconnecting about 400
acupoints. These acupoints correspond to specific areas
on the surface of the body, which demonstrate higher electrical
conductance because of the presence of higher density of
gap junctions along cell borders. They act as converging
points (or sinks) for electromagnetic fields. A higher metabolic
rate, temperature, and calcium ion concentration, are also
observed at these points. In principle, positive (anode)
pulse stimulation of a point inhibits the organ function,
whereas negative (cathode) pulse stimulation enhances that
function (18). This forms the basis of electroacupuncture,
which applies small electrical needles inserted in specific
acupoints.
Effects of acupuncture on the hypothalamic-pituitary-ovarian
axis and menstrual cycle
Although traditional Chinese medicine understanding of
acupuncture is based on ancient medical theory, a modern
and scientific neuroendocrine perspective has begun to evolve
in the past two decades. Mayer et al. (19) first reported
that acupuncture analgesia was induced through endorphin
production and antagonized by the narcotic antagonist naloxone.
Other studies similarly suggested that certain effects of
acupuncture are mediated through the nervous system, within
which ß-endorphin and other neuropeptides have been
implicated (20-22).
Acupuncture was shown by Petti et al. (20) to cause a significant
increase in ß-endorphin levels during treatment, which
lasted for up to 24 hours. ß-endorphin is derived
from its precursor protein pro-opiomelanocortin, which is
present in abundant amounts in neuronal cells of the arcuate
nucleus of the hypothalamus, pituitary, medulla, and in
peripheral tissues including intestines and ovaries (23-25).
Pro-opiomelanocortin cleaves to form adrenocorticotropic
hormone and ß-lipoprotein. Further cleavage of ß-lipoprotein
yields neuropeptides including ß-endorphin. Aleem
et al. (26, 27) demonstrated the presence of immunoreactive
ß-endorphin in follicular fluids of both normal and
polycystic ovaries.
The influence on gonadotropin secretion and the menstrual
cycle by endogenous opioid peptides is believed to be mediated
by their action on GnRH secretion (28). The hypothalamic
ß-endorphin center and the GnRH pulse generator, in
fact, are both situated within the arcuate nucleus. Quigley
et al. (29) first reported an increased opioid inhibition
of LH secretion in hyperprolactinemic patients with pituitary
microadenomas. Ching (30) and Orstead and Spics (31), respectively,
showed that opioid peptides suppress GnRH release in rats
and rabbits.
The role of these neuropeptides, including ß-endorphin,
in the regulation of GnRH secretion in humans has recently
been reviewed by Kalra et al. (32) and Pau and Spies (33).
Rossmanith et al. (34) demonstrated the role of opioid peptides
in the initiation of the mid-cycle LH surge in normal cycling
women. Meanwhile, measurement of ß-endorphin in ovarian
follicular fluid of healthy ovulatory women revealed much
higher levels than that in circulating plasma (35). The
highest level of ß-endorphin was noted to be in the
preovulatory follicle.
Because acupuncture treatment impacts on ß-endorphin
levels, which in turn affect GnRH secretion and the menstrual
cycle, it is logical to hypothesize that acupuncture may
influence ovulation and fertility. Animal studies have revealed
that acupuncture treatment normalized GnRH secretion and
affected peripheral gonadotropin levels (36, 37). Various
investigators have shown that in normally ovulatory or anovulatory
women, acupuncture also influenced plasma levels of FSH,
LH, E2, and P (38-40). Acupuncture as a surrogate for hCG
in ovulation induction was successfully used by Cai (41).
Chen and Yu (42) showed that electroacupuncture normalized
they hypothalamic-pituitary-ovarian axis, and in another
study Chen (43) reported that 6 of 13 anovulatory cycles
responded to acupuncture treatment.
A series published from the University of Heidelberg in
Germany (44) used auricular acupuncture on 45 infertile
women suffering from ovulatory dysfunction such as oligomenorrhea
and luteal phase defect. The control group received medical
treatment including bromocriptine, dexamethasone, levothyroxine,
clomiphene citrate (CC), and gonadotropin. Although the
investigators concluded that resumption of ovulatory cycles
occurred significantly more often in the acupuncture group
compared to the control group, pregnancy rates were not
different between the two groups. However, interpretation
of study data was very difficult due to the heterogeneity
of the patient population and treatment modalities. Moreover,
seven pregnancies in the acupuncture group were actually
achieved with hormone treatment 6 months after acupuncture
was stopped.
Another study by Stenver-Victorin et al. (45) evaluated
the use of electroacupuncture for ovulation induction on
24 oligo/amenorrheic women with polycycstic ovarian syndrome
(PCOS). The percentage of ovulatory cycles in all subjects
was shown to improve from 15% (in a total of 3 months before
treatment) to 66% up to 3 months after treatment. Responsive
patients were noted to have significantly lower body mass
index (BMI), waist-to-hip circumference ratio, serum T concentration,
serum T/sex hormone-binding globulin ratio, and serum basal
insulin level. They suggested that, in these selected patients
with PCOS, acupuncture could be considered as an alternative
or adjunct to pharmacological ovulation induction.
A recent prospective randomized controlled study by Paulus
et al. (46) compared pregnancy rates in a total of 160 patients
undergoing IVG. Acupuncture was performed in 80 patients
25 minutes before and after ET. After controlling confounding
variables, clinical pregnancy rate for the acupuncture group
(42.5%) was significantly higher than the control group
(26.3%).
Peripheral effects of acupuncture
In addition to the central modulation of the hypothalamic-pituitary-ovarian
axis, the effects of acupuncture on the autonomic nervous
system have been well documented (47). In the early 1980s,
Yao et al. (48) reported long-lasting cardiovascular depression
induced by acupuncture stimulation of the sciatic nerve
in unanesthetized hypertensive rats. In the human, acupuncture
was also shown to be sympathoinhibitory. After acupuncture,
sympathetic nerve activity as measured by norepinephrine
level, skin temperature, blood pressure, and pain tolerance
threshold was shown to be decreased (49).
Endometrial thickness, morphology, and uterine artery blood
flow have been implicated as important parameters for success
of implantation of human embryos (50-57). Despite conflicting
results in the utilization of these parameters during various
stages of treatment to predict outcome in IVF, it is generally
believed that adequate endometrial thickness is required
to optimize pregnancy rate. Because endometrial thickness
is a function of uterine artery blood flow, Sher and Fisch
(58) reported a novel method of using vaginal sildenafil
in an attempt to improve uterine artery blood flow and endometrial
development in patients undergoing IVF.
With its central sympathoinhibitory effect, acupuncture
may contribute to reduce uterine artery impedance and therefore,
increase blood flow to the uterus. In fact, Sterner-Victorin
et al. (59) demonstrated this when they performed acupuncture
in 10 infertile women who were down-regulated by GnRH analog
to avoid the effect of endogenous hormone on the uterine
artery blood flow.
Pulsatility index in the uterine artery and skin temperature
(on the forehead and lumbosacral area) were evaluated in
three time periods-before, right after, and 2 weeks after
acupuncture treatment (twice a week for 4 weeks). Pulsatility
index and skin temperatures were found to be significantly
decreased and increased, respectively, both right after
and 14 days after acupuncture treatment. This effect was
hypothesized to be caused by central inhibition of sympathetic
activity.
Acupuncture and stress reduction
It has been well documented that infertility causes stress
(60-65), and stress reduction may, in turn, improve fertility
(66). However, the relationship between stress and infertility
is that of a vicious cycle. Social stigmatization, decreased
self-esteem, unmet reproductive potential of sexual relationship,
physical and mental burden of treatment, and the lack of
control on treatment outcome are just some of the factors
that can lead to psychological stress in any couple pursuing
infertility treatment. In turn, stress may lead to the release
of stress hormones and influence mechanisms responsible
for a normal ovulatory menstrual cycle through its impact
on the hypothalamic-pituitary-ovarian axis.
The use of acupuncture for reducing anxiety and stress
possibly through its sympathoinhibitory property and impact
on ß-endorphin levels has been reviewed (67, 68),
and the efficacy of acupuncture in depression has also been
studied (69). Because the pharmacological side effects of
anxiolytic and antidepressant drugs on infertility treatment
outcome are largely unknown, acupuncture may provide an
excellent alternative for stress reduction in women undergoing
infertility treatment.
Discussion
The practice of acupuncture to treat identifiable patho-physiological
conditions has been a subject of intense research. The underlying
physiologic mechanisms of acupuncture such as the release
of opioids and other peptides in the central peripheral
nervous system, and its inhibition of the sympathetic nervous
system have been increasingly established. Promising results
from credible trials have emerged for the use of acupuncture
in treating various pain syndromes, substance abuse, and
chemotherapy-induced nausea and vomiting.
Although the definitive role of acupuncture in the treatment
of female infertility is yet to be established, its neuroendocrine
effect on the hypothalamic-pituitary-ovarian axis and the
preliminary clinical data reviewed here justifies further
clinical trials to systematically examine the efficacy of
acupuncture in treating various conditions related to female
infertility such as ovulatory dysfunction associated with
PCOS. The peripheral impact of acupuncture in improving
uterine artery blood flow and hence endometrial thickness
also provides encouraging data regarding its potential positive
effect on implantation.
Whether these potential beneficial effects of acupuncture
on the reproductive system can be translated into improving
infertility treatment outcomes will eventually mandate randomized
controlled studies of adequate design. Because acupuncture
is nontoxic and relatively affordable, its indications as
an adjunct in assisted reproduction or as an alternative
for women who are intolerant, ineligible, or contraindicated
for conventional hormone induction of ovulation deserves
serious research and exploration.
Appropriate training, credentialing, and certification
of acupuncture practitioners by state agencies can facilitate
the integration of acupuncture into the treatment of female
infertility, and healthcare in general. The NIH Consensus
Conference (1) agreed that this is necessary to allow the
public and other health practitioners to identify qualified
acupuncture practitioners. With the help of the US Department
of Education, issues of training and licensure of non-physician
and physician practitioners have been addressed. There is
sufficient evidence to acupuncture's value to expand its
use into conventional medicine and treatment of female infertility,
and to encourage further studies of its underlying mechanisms
as well as to establish its clinical value.
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FERTILITY AND STERILITY® VOL. 78, NO. 6,
DEC. 2002
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