Beruflich Dokumente
Kultur Dokumente
Abstract
The use of acupuncture to improve the outcome of in vitro fertilisation (IVF) has become widespread over the past
five years. Three of four randomised controlled trials (RCT) published since 2002 have shown that acupuncture
significantly increases pregnancy rates. Although the research has a number of methodological limitations, it does
strongly endorse the use of acupuncture during IVF. Protocols for IVF are complex, involving multiple phases with
specific physiological aims. Correspondingly, acupuncture treatments before and during IVF need to be carefully
considered in relation to the biomedical aspects that are being manipulated. This article summarises recent research
in this area, and provides an explanation of the IVF process and associated acupuncture treatment guidelines.
Introduction
10days-2months
10-14d
33-35hr 3-5d
14 days after oocyte retrieval
|----------------------------------------|---------------------------------|-------|----------------|------------------------------------------|
timing & hormonal
ovulation
hCG oocyte embryo
1st pregnancy
down-regulation
induction
trigger retrieval transfer
test (hCG)
Laboratory component
In the laboratory, oocytes are identied under a
microscope, graded for maturity, and placed in an
incubation medium in a petri dish by an embryologist.
Oocytes are generally cultured for three to six hours
before being exposed to sperm.
The sperm may have already undergone several
procedures to help improve the quality of the sample
to be utilised. In cases of poor sperm quality or low
numbers, the sperm may be injected directly into the
oocyte in a procedure called intracytoplasmic sperm
injection or ICSI.
The sperm and oocytes are incubated overnight
in an incubation medium with nutrients that allow
fertilisation to occur. The next morning, the oocytes
are checked for signs of fertilisation and then on the
following days for development. Not all the eggs will
fertilise and not all of the fertilised eggs will continue
to divide. The embryos will be allowed to grow to the
ve to six-cell to eight-cell stage (day three) or to the
blastocyst stage (day ve) before being returned to
the womans uterus.
Embryo transfer
Prior to embryo transfer (ET), the embryos are
graded in terms of appearance and development.
The best embryos are selected and gently placed into
the uterus via a catheter inserted through the cervix.
Embryo transfer is an outpatient procedure, which
takes only a few minutes to perform and no pain
relief is required. Most programs transfer two to three
embryos in patients under age 35 and three+ embryos
in women over 35 to maximise the chance of success.
If there are additional embryos, they can be frozen for
use later if implantation and pregnancy do not occur.
Luteal phase monitoring
In order to help support the endometrium and
increase the chance of success, progesterone is given
in either vaginal suppositories, injections with oil,
or micronised oral tablets. A pregnancy (hCG) test is
given 14 days after oocyte retrieval.
Side effects of IVF
The process of IVF can be quite gruelling for the
patient. It involves receiving numerous injections
of drugs, with subsequent soreness and bruising, as
well as getting up early to get to the IVF centre for
Figure 1:
Timeline
for IVF
29
30
Author/Year
Study
design
Study
population
Interventions/
sample size
MA
25 min before and after ET
1. Paulus et al,
2002
RCT
160 women
Age 32.5 y;
range 28.536.5 y
Acu (n=80)
Control: No Acu
(n=80)
Relevant
Outcomes
measured
Results
Clinical pregnancy
- presence of a
foetal sac (by
ultrasound) 6 wk
post ET
Uterine artery
pulsatility index
Acupuncture treatment
2. Dieterle et
al, 2006
3. Smith et al,
2006
RCT
RCT
225 Women
Avg age 34.9
y; range 31.338.9 y
128 Women
Avg age 36 y;
range 31.240.9 y
Acu (n=116)
Control: placebo
Acu (sham pts)
(n=109)
Acu (n=110)
Control: Placebo
(sham pts,
Streitberger)
(n=118)
MA
25 min before & after ET (Acu-1); plus
2 days post ET (Acu-2)
4. Westergaard
et al, 2006
RCT
273 Women
Avg age 37 y;
range 24-45 y
Acu-1 tx (n=95)
Acu -2 tx (n=91)
Control: no acu
(n=87)
Clinical preg
Ongoing preg
Acu-1 group
compared to control
had sign higher clinical
and ongoing preg rates
(39% vs 26% & 36% vs
22%)
Acu-2 group not sign
diff to control
Acu-2 had a higher,
but not sign, early preg
loss compared to Acu1 & control (33% vs
15% vs 21%)
Abbreviations: Acu acupuncture; Avg average; ET embryo transfer; MA manual acupuncture; preg pregnancy; RCT randomised
controlled trial; sign signicant to at least p < 0.05; y year; Tx treatment
Table 1:
Summary of
RCTs Evaluating
Acupuncture
as an Adjunct
Therapy for IVF
31
32
33
Acupuncture treatments
Phase 1
2
3
4
5
|-------------------------|-----------------------|---------------------------------------|-------------------|------------------------------------------------------|
Tx Prep for IVF Tx during
Tx during ovulation induction Tx before/ after
Tx to maintain pregnancy
TCM Pattern Dx down-regulation
embryo transfer
Acupuncture treatment phases (Liang, 2003)
Phase 1: Tx (treatment) is according to the TCM Dx (differentiation)
Phase 2: Zusanli ST-36, Sanyinjiao SP-6, Taichong LIV-3, Hegu L.I.-4, Yintang (Modication: Xuehai SP-10, Zigongxue M-CA-18)
Phase 3: Zusanli ST-36, Sanyinjiao SP-6, Taichong LIV-3, Hegu L.I.-4, Taixi KID-3, Yintang, Baihui DU-20, Zigongxue M-CA-18
Phase 4: Before ET: Zusanli ST-36, Sanyinjiao SP-6, Taichong LIV-3, Hegu L.I.-4, Taixi KID-3, Yintang, Qixue KID-13, Baihui DU-20, Sishencong M-HN-1; Ear Shenmen, Kidney, Liver,
Spleen; After ET: Zusanli ST-36, Taixi KID-3, Yintang M-HN-3, Baihui DU-20, and Ear Kidney, Shenmen, point halfway between Liver and Spleen
Phase 5: Up to 1st hCG: use after ET protocol
After positive hCG: Yintang, Baihui DU-20, and Ear Kidney, Shen Men, point halfway between Liver and Spleen
In case of threatened miscarriage: Baihui DU-20, Sishencong M-CA-18, Yintang M-HN-3, Ear Shenmen, Kidney, point halfway between Liver and Spleen
Figure 2:
Timeline for
acupuncture
treatments
during IVF
34
TCM Diagnosis
Acupuncture Points
Kidney jing
deciency
Kidney yin
deciency
Malar ush, night sweats, thirst, symptoms worse in afternoon and evening,
insomnia, restlessness, irritability, weak/sore lower back and knees, hot
ashes; Period-scanty or heavy bright red
Pulse-rapid, ne; Tongue-red, peeled
Kidney yang
deciency
Blood deciency
Dry eyes, dry skin, pale complexion, brittle nails, dizziness, poor memory,
fatigue, numbness; Period-amenorrhoea, irregular periods, long cycle length,
scanty period
Pulse-weak, ne, empty; Tongue-pale
Qi deciency
Heart qi
stagnation
Palpitations, anxiety, insomnia, hysteria/neurosis, emotional stress; Periodirregular, or amenorrhoea which was preceded by emotional shock
Pulse-knotted (esp. left 1st position); Tongue-red tip
Table 2: TCM
diagnostic
patterns
of female
infertility,
associated
signs and
symptoms, and
acupuncture
points
commonly used
for treatment.
Conclusions
Acknowledgements
35
References
Anderson, B.J., Haimovici, F., Ginsburg,
E.S, Schust, D.J. & Wayne, P.W. (2007).
In vitro fertilisation and acupuncture:
clinical efcacy and mechanistic basis,
Alternative Therapies in Health and
Medicine, 13(3), 38-48.
Anderson, B.J. & Rosenthal, L. (2007).
Acupuncture and IVF studies lack
protocol analysis and external validity,
Fertil Steril, 87(4), 1000.
Beal MW. (1998). Women's use of
complementary and alternative therapies
in reproductive health care, J Nurse
Midwifery, 43(3), 224-34.
Birch S. (2003). Controlling for non-specic
effects of acupuncture in clinical trials,
Clinical Acupuncture and Oriental
Medicine, 4(2-3), 59-70.
Collins J. (May 2006). The play of chance,
Fertil Steril, 85(5), 1364-7.
Dieterle S, Ying G, Hatzmann W & Neuer
A. (May 2006). Effect of acupuncture
on the outcome of in vitro fertilisation
and intracytoplasmic sperm injection:
a randomized, prospective, controlled
clinical study, Fertil Steril, 85(5),
1347-51.
Domar, AD. (2006). Acupuncture and
infertility: we need to stick to good
science, Fertil Steril., 85(5):1359-61.
Kaptchuck TJ. (2002). The placebo
effect in alternative medicine: can the
performance of a healing ritual have
clinical signicance? Ann Intern Med
136(11), 817-25.
Kovacs GT, Maclachlan V & Brehny S. (2001).
What is the probability of conception for
couples entering an IVF program? Aust
N Z J Obstet Gynaecol 41(2), 207-9.
Liang, L. (2003). Acupuncture and IVF. Blue
Poppy Press: Boulder.
Lyttleton, J. (2004). Treatment of Infertility with
Chinese Medicine. Churchill Livingstone:
London.
Maciocia, G. (1998). Obstetrics and Gynecology
in Chinese Medicine. Churchill Livingstone:
London.
Myers ER. (2006). Acupuncture as adjunctive
therapy in assisted reproduction:
remaining uncertainties, Fertil Steril.
85(5),1362-3.
MacPherson H, White A, Cummings M,
Jobst K, Rose K, & Niemtzow R. (2001).
Standards for reporting interventions
in controlled trials of acupuncture:
the STRICTA recommendations,
Complement Ther Med 9(4), 246-9.