Those who received acupuncture increased their chances of conceiving by 65 percent.
February 8, 2008
Vittorio Hernandez - AHN News Writer
London, England (AHN) - Seven scientific trials among 1,366 women of different ages who found it difficult to conceive showed that having acupuncture at the same time the embryo was placed inside the womb during an in vitro fertilization procedure more than doubles the chance of the woman becoming pregnant.
The study was made by researchers at the University of Maryland School of Medicine and the VU University Amsterdam. It compared results of women who underwent acupuncture, those who were given fake needle treatments and those who had no extra therapy.
Those who received acupuncture increased their chances of conceiving by 65 percent, the study said. The British Medical Journal published the result of the medical breakthrough Friday.
While the study did not clearly explain how acupuncture aids fertility, experts theorized it could possible be the relaxing effect of acupuncture on the IVF procedure, considered extremely stressful.
Compared with repeated fertility treatment cycles which costs $7,785 (4,000 pound) per cycle in Britain, the acupuncture therapy is easier on the pocket.
One percent of births in the U.K. or 11,000 babies out of 32,000 IVF procedures are born every year in the U.K. The findings will be particularly significant for many western nations grappling with dwindling populations.
Influence of acupuncture on the pregnancy rate in patients who undergo assisted reproduction therapy
Wolfgang E. Paulus, M.D.,[a] Mingmin Zhang, M.D.,[b] Erwin Strehler, M.D.,[a]
Imam El-Danasouri, Ph.D.,[a] and Karl Sterzik, M.D.[a]
Christian-Lauritzen-Institut, Ulm, Germany
Received June 5, 2001; revised and accepted October 16, 2001. Reprint requests: Wolfgang E. Paulus, M.D., Christian-Lauritzen-Institut, Frauenstr. 51, D-89073, Ulm, Germany (FAX: ++49-731-9665130; E-mail: email@example.com).
[a] Department of Reproductive Medicine, Christian-Lauritzen-Institut.
[b] Department of Traditional Chinese Medicine, Tongji Hospital, Tongji Medical University, Wuhan, People's Republic of China.
Objective: To evaluate the effect of acupuncture on the pregnancy rate in assisted reproduction therapy (ART) by comparing a group of patients receiving acupuncture treatment shortly before and after embryo transfer with a control group receiving no acupuncture.
Design: Prospective randomized study.
Setting: Fertility center.
Patient(s): After giving informed consent, 160 patients who were undergoing ART and who had good quality embryos were divided into the following two groups through random selection: embryo transfer with acupuncture (n = 80) and embryo transfer without acupuncture (n = 80).
Intervention(s): Acupuncture was performed in 80 patients 25 minutes before and after embryo transfer. In the control group, embryos were transferred without any supportive therapy.
Main Outcome Measure(s): Clinical pregnancy was defined as the presence of a fetal sac during an ultrasound examination 6 weeks after embryo transfer.
Result(s): Clinical pregnancies were documented in 34 of 80 patients (42.5%) in the acupuncture group, whereas pregnancy rate was only 26.3% (21 out of 80 patients) in the control group.
Conclusion(s): Acupuncture seems to be a useful tool for improving pregnancy rate after ART. (Fertil Steril®2002;77:721- 4. ©2002 by American Society for Reproductive Medicine.)
Key Words: Acupuncture, assisted reproduction, embryo transfer, pregnancy rate
Acupuncture is an important element of traditional Chinese medicine (TCM), which can be traced back for at least 4,000 years. Acupuncture has been shown to alleviate nausea and vomiting, dental pain, addiction, headache, menstrual cramps, tennis elbow, fibromyalgia, myofascial pain, osteoarthritis, carpal tunnel syndrome, and asthma. Both physiologic and psychological benefits of acupuncture have been scientifically demonstrated in recent years.
However, so far there have been only a few serious trials concerning the use of acupuncture in reproductive medicine. Publications focus primarily on acupuncture therapy for male infertility (1, 2). Electroacupuncture may reduce blood flow impedance in the uterine arteries of infertile women (3). A positive impact of electroacupuncture on endocrinologic parameters and ovulation in women with polycystic ovary syndrome has been demonstrated (4). In addition, auricular acupuncture was successfully used in the treatment of female infertility (5). In the present study, we chose acupuncture points that relax the uterus according to the principles of TCM. Because acupuncture influences the autonomic nervous system, such treatment should optimize endometrial receptivity (6). Our main objective was to evaluate whether acupuncture accompanying embryo transfer increases clinical pregnancy rate.
Materials and Methods
This study was a prospective randomized trial at the Christian-Lauritzen-Institut in Ulm, Germany. It was approved by the ethics committee of the University of Ulm. A total of 160 healthy women undergoing treatment with in vitro fertilization (IVF; n = 101) or intracytoplasmic sperm injection (ICSI; n = 59) were recruited into the study. The age of the patients ranged from 21 to 43 (mean age: 32.5 = 4.0 years). The cause of infertility was the same for both groups (Table 1). Only patients with good embryo quality were included in the study. Using a computerized randomization method, patients were assigned into either the acupuncture group or the control group.
NS = not significant (P>.05).
Paulus. Acupuncture in ART. Fertil Steril 2002.
Ovarian stimulation, oocyte retrieval, and in vitro culture were performed as previously described (7). Transvaginal ultrasound-guided needle aspiration of follicular fluid was performed 36 to 38 hours after hCG administration. Immediately after follicle puncture, the oocytes were retrieved, assessed, and fertilized in vitro. Sperm preparation and culture conditions did not differ for either group.
In cases of severe male subfertility, ICSI was preferred, as described in the literature (8). Forty-eight hours after the IVF or ICSI procedure, embryos were evaluated according to their appearance as type 1 or 2 (good), type 3 or 4 (poor), as described in literature (9).
Just before and after embryo transfer, all patients underwent ultrasound scans of the uterus using a 7-MHz transvaginal probe (LOGIQ 400 Pro, GE Medical Systems Ultra-sound Europe, Solingen, Germany). Pulsed Doppler curves of both uterine arteries were measured by one observer. The pulsatility index (PI) for each artery was calculated electronically from a smooth curve fitted to the average waveform over three cardiac cycles.
A maximum of three embryos, in accordance with German law, were transferred into the uterine cavity on day 2 or 3 after oocyte retrieval. For embryo replacement, the patient was placed in a dorsal lithotomy position, with an empty bladder. The cervix was exposed with a bivalved speculum, then washed with culture media prior to embryo transfer. Labotect Embryo Transfer Catheter Set (Labotect GmbH, Go¨ ttingen, Germany) was used for atraumatic replacement owing to the curved guiding cannula with a ball end, allowing the set to be used reliably even with difficult anatomic conditions. The metallic reinforced inner catheter shaft al lowed safe passage through the cervical canal. When the catheter tip lay close to the fundus, the medium containing the embryos was expelled and the catheter withdrawn gently. After this procedure, the patient was placed at bed rest for 25 minutes. All oocyte retrievals and embryo transfers were performed by one examiner using the same method. The examiner was not aware of the patient's treatment group (control or acupuncture).
At the time of the embryo transfer, blood samples (10 mL) were obtained from the cubital vein. Plasma estrogen was determined by an immunometric method using the IMMULITE 2000 Immunoassay System (DPC Diagnostic Product Corporation, Los Angeles, CA).
Luteal phase support was given by transvaginal progesterone administration (Utrogest®, 200 mg, three times per day; Kade, Berlin, Germany). Progesterone administration was initiated on the day after oocyte retrieval and was continued until the serum ß-hCG measurement 14 to 16 days after transfer and, in cases of pregnancy, until gestation week 8.
Each patient in the experimental group received an acupuncture treatment 25 minutes before and after embryo transfer. Sterile disposable stainless steel needles (0.25 X 25 mm) were inserted in acupuncture point locations. Needle reaction (soreness, numbness, or distention around the point = Deqi sensation) occurred during the initial insertion. After 10 minutes, the needles were rotated in order to maintain Deqi sensation. The needles were left in position for 25 minutes and then removed. The depth of needle insertion was about 10 to 20 mm, depending on the region of the body undergoing treatment. Before embryo transfer, we used the following locations: Cx6 (Neiguan), Sp8 (Diji), Liv3 (Taichong), Gv20 (Baihui), and S29 (Guilai).
After embryo transfer, the needles were inserted at the following points: S36 (Zusanli), Sp6 (Sanyinjiao), Sp10 (Xuehai), and Li4 (Hegu).
In addition, we used small stainless needles (0.2 X 13 mm) for auricular acupuncture at the following points, without rotation: ear point 55 (Shenmen), ear point 58 (Zhigong), ear point 22 (Neifenmi), and ear point 34 (Naodian). Two needles were inserted in the right ear, the other two needles in the left ear. The four needles remained in the ears for 25 minutes. The side of the auricular acupuncture was changed after embryo transfer. The patients in the control group also remained lying still for 25 minutes after embryo transfer. All treatments were performed by the same well-trained examiner, in the same way.
The primary point of the study was to determine whether acupuncture improves the clinical pregnancy rate after IVF or ICSI treatment. Student's t-test was used as a corrective against any possible imbalance between the two groups regarding the following variables: age of patient, number of previous cycles, number of transferred embryos, endometrial thickness, plasma estradiol on day of transfer, method of treatment (IVF or ICSI), and blood flow impedance in the uterine arteries (pulsatility index). Chi-square test was used to compare the two groups. All statistical analyses were carried out using the software package Statgraphics (Manugistics, Inc., Rockville, MD).
A total of 160 patients was recruited for the study. Patients who failed to conceive during the first treatment cycle were not reentered into the study. According to the randomization, 80 patients were treated with acupuncture, and 80 patients underwent the usual therapy without acupuncture.
As Table 1 shows, there were no statistically significant differences between the two groups with respect to the following covariants: age of patient, number of previous cycles, number of transferred embryos, endometrial thickness, plasma estradiol on day of transfer, or method of treatment (IVF or ICSI). Clinical indications for ART were the same for patients of both groups. The blood flow impedance in the uterine arteries (pulsatility index) did not differ between the groups before and after embryo transfer.
The analysis shows that the pregnancy rate for the acupuncture group is considerably higher than for the control group (42.5% vs 26.3%; P=.03).
The acupuncture points used in this study were chosen according to the principles of TCM (10): Stimulation of Taiying meridians (spleen) and Yangming meridians (stomach, colon) would result in better blood perfusion and more energy in the uterus. Stimulation of the body points Cx6, Liv3, and Gv20, as well as stimulation of the ear points 34 and 55, would sedate the patient. Ear point 58 would influence the uterus, whereas ear point 22 would stabilize the endocrine system.
The anesthesia-like effects of acupuncture have been studied extensively. Acupuncture needles stimulate muscle afferents innervating ergoreceptors, which leads to increased ß-endorphin concentration in the cerebrospinal fluid (11). The hypothalamic ß-endorphinergic system has inhibitory effects on the vasomotor center, thereby reducing sympathetic activity. This central mechanism, which involves the hypothalamic and brainstem systems, controls many major organ systems in the body (12). In addition to central sympathetic inhibition by the endorphin system, acupuncture stimulation of the sensory nerve fibers may inhibit the sympathetic outflow at the spinal level. By changing the concentration of central opioids, acupuncture may also regulate the function of the hypothalamic-pituitary-ovarian axis via the central sympathetic system (13).
Kim et al. (14) suggested that Li4 acupuncture treatment could be useful in inhibiting the uterus motility. In their rat experiments, treatment on the Li4 acupoint suppressed the expression of COX-2 enzyme in the endometrium and myometrium of pregnant and nonpregnant uteri.
Stener-Victorin et al. (3) reduced high uterine artery blood flow impedance by a series of eight electroacupuncture treatments, twice a week for 4 weeks. They suggest that a decreased tonic activity in the sympathetic vasoconstrictor fibers to the uterus and an involvement of central mechanisms with general inhibition of the sympathetic outflow may be responsible for this effect. In our study, we could not see any differences in the pulsatility index between the acupuncture and control group before or after embryo transfer. This may be due to a different acupuncture protocol and the selected sample of patients with high blood flow impedance of the uterine arteries (PI = 3.0) in the Stener-Victorin et al. study.
As we could not observe any significant differences in covariants between the acupuncture and control groups, the results demonstrate that acupuncture therapy improves pregnancy rate.
Further research is needed to demonstrate precisely how acupuncture causes physiologic changes in the uterus and the reproductive system. To rule out the possibility that acupuncture produces only psychological or psychosomatic effects, we plan to use a placebo needle set as a control in a future study.
1. Siterman S, Eltes F, Wolfson V, Lederman H, Bartoov B. Does acupuncture treatment affect sperm density in males with very low sperm count? A pilot study. Andrologia 2000;32:31-9.
2. Bartoov B, Eltes F, Reichart M, Langzam J, Lederman H, Zabludovsky N. Quantitative ultramorphological analysis of human sperm: fifteen years of experience in the diagnosis and management of male factor infertility. Arch Androl 1999;43:13-25.
3. Stener-Victorin E, Waldenstrom U, Andersson SA, Wikland M. Reduction of blood flow impedance in the uterine arteries of infertile women with electro-acupuncture. Hum Reprod 1996;11:1314 -7.
4. Stener-Victorin E, Waldenstrom U, Tagnfors U, Lundeberg T, Lindst-edt G, Janson PO. Effects of electro-acupuncture on anovulation in women with polycystic ovary syndrome. Acta Obstet Gynecol Scand 2000;79:180 -8.
5. Gerhard I, Postneek F. Auricular acupuncture in the treatment of female infertility. Gynecol Endocrinol 1992;6:171-81.
6. Stener-Victorin E, Lundeberg T, Waldenstrom U, Manni L, Aloe L, Gunnarsson S, Janson PO: Effects of electro-acupuncture on nerve growth factor and ovarian morphology in rats with experimentally induced polycystic ovaries. Biol Reprod 2000;63:1497-503.
7. Strehler E, Abt M, El-Danasouri I, De Santo M, Sterzik K. Impact of recombinant follicle-stimulating hormone and human menopausal gonadotropins on in vitro fertilization outcome. Fertil Steril 2001;75: 332-6.
8. Palermo GD, Schlegel PN, Colombero LT, Zaninovic N, Moy F, Rosenwaks Z. Aggressive sperm immobilization prior to intracytoplasmic sperm injection with immature spermatozoa improves fertilization and pregnancy rates. Hum Reprod 1996;11:1023-9.
9. Plachot M, Mandelbaum J: Oocyte maturation, fertilization and embryonic growth in vitro. Br Med Bull 1990;46:675-94.
10. Maciocia G. Obstetrics and gynecology in Chinese medicine. New York: Churchill Livingstone, 1998.
11. Hoffmann P, Terenius L, Thoren P. Cerebrospinal fluid immunoreactive beta-endorphin concentration is increased by voluntary exercise in the spontaneously hypertensive rat. Regul Pept 1990;28:233-9.
12. Andersson SA, Lundeberg T. Acupuncture-from empiricism to science: functional background to acupuncture effects in pain and disease. Med Hypotheses 1995;45:271-81.
13. Chen BY, Yu J. Relationship between blood radioimmunoreactive beta-endorphin and hand skin temperature during the electro-acupuncture induction of ovulation. Acupunct Electrother Res 1991;16:1-5.
14. Kim J, Shin KH, Na CS. Effect of acupuncture treatment on uterine motility and cyclooxygenase-2 expression in pr
Effect of acupuncture on the outcome of in vitro fertilization and intracytoplasmic sperm injection: a randomized, prospective, controlled clinical study
Stefan Dieterle, M.D.,a Gao Ying, M.D.,a,b Wolfgang Hatzmann, M.D.,a and Andreas Neuer, M.D. a Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Witten/ Herdecke, Dortmund, Germany; and b Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
Objective: To determine the effect of luteal-phase acupuncture on the outcome of IVF/intracytoplasmic sperm injection (ICSI).
Design: Randomized, prospective, controlled clinical study.
Setting: University IVF center.
Patient(s): Two hundred twenty-five infertile patients undergoing IVF/ICSI.
Intervention(s): In group I, 116 patients received luteal-phase acupuncture according to the principles of traditional Chinese medicine. In group II, 109 patients received placebo acupuncture.
Main Outcome Measure(s): Clinical and ongoing pregnancy rates.
Result(s): In group I, the clinical pregnancy rate and ongoing pregnancy rate (33.6% and 28.4%, respectively) were significantly higher than in group II (15.6% and 13.8%).
Conclusion(s): Luteal-phase acupuncture has a positive effect on the outcome of IVF/ICSI. (Fertil Steril 2006; 85:1347-51. ©2006 by American Society for Reproductive Medicine.)
Key Words: Acupuncture, assisted reproduction, pregnancy rate, IVF, ICSI
The scientific clinical significance of acupuncture is the subject of controversy. Acupuncture is an ancient traditional Chinese treatment technique with an empirical basis. Its theory is based on the energy flow of Qi. Imbalances are believed to cause diseases, which can be treated by stimulating specific points on the body surface. However, the scientific rationale has yet to be established. Studies have suggested that the effects of acupuncture might be mediated through neuropeptides in the central nervous system (1, 2).
A National Institutes of Health Consensus Development Panel (3) found effects of acupuncture on nausea, vomiting, and pain. A randomized, placebo-controlled patient and observer blind trial demonstrated the effectiveness of acupuncture on nausea and vomiting (4).
The role of acupuncture in the treatment of female infertility is unclear (5). Options for patients who undergo several IVF/intracytoplasmic sperm injection (ICSI) cycles without success remain unsatisfactory. Various approaches have been suggested to increase the pregnancy rate. It has been shown that the receptivity of the endometrium (6) and the uterine contraction frequency at the time of ET (7) are critical for embryo implantation. In a previous randomized, prospective, controlled study, it was demonstrated that acupuncture before and after ET resulted in a higher pregnancy rate compared with a group without acupuncture (8). Further studies were suggested with a placebo control group (9).
The aim of this study was to investigate the effect of luteal-phase acupuncture on IVF/ICSI outcome. To minimize psychological effects, a group of patients with acupuncture according to the principles of traditional Chinese medicine was compared with a group of patients receiving placebo acupuncture.
MATERIALS AND METHODS
The present investigation was designed as a randomized, prospective, controlled trial. The study was approved by the institutional review board. Written, informed consent was obtained from each participant. All patients underwent IVF or ICSI and participated only once.
Patients were randomized with sealed randomization envelopes. A total of 225 infertile patients were included: 116 women were randomized into group I (study group), and 109 women were randomized into group II (control group). The random allocation was concealed from the physician performing the ET. All patients received acupuncture by the same physician.
All patients were down-regulated according to the long protocol, with a GnRH agonist (nafarelin 0.4 mg daily), beginning on day 21 of the previous cycle until the day of hCG injection. Ovarian stimulation was performed with recombinant FSH or hMG. Ovulation was triggered with hCG (10,000 IU) when at least three follicles had a diameter of 18 mm with an adequate serum E2 concentration. Transvaginal oocyte retrieval was performed under ultrasound guidance 35 hours after hCG administration.
According to the German Embryo Protection Law, a maximum number of three embryos was transferred into the uterus 2 to 3 days after oocyte retrieval. Embryo selection is not allowed in Germany. In addition, the German Board of Physicians recommends a transfer of two embryos for women aged 35 years. Patients in both groups were supplemented with P (200 mg three times daily) starting the day after oocyte retrieval. Biochemical pregnancies were diagnosed by serum hCG measurement 2 weeks after ET. Clinical pregnancies were confirmed by transvaginal ultrasound 4 - 6 weeks after ET demonstrating at least one gestational sac.
For acupuncture, 4-cm-long disposable stainless steel needles (Suzhou Acupuncture and Medical Instruments Co. Ltd., Suzhou, Jiangsu, P. R. China) were used. In both groups, acupuncture was applied for 30 minutes immediately after ET and again 3 days later. The needles were inserted to a depth of 15-30 mm, depending on the region of the body. They were rotated to evoke the needle reaction of Deqi sensation (numbness, soreness, and distention around the acupoint). Fifteen minutes later, the needles were rotated again to maintain Deqi sensation. After ET, the following acupoints were used in group I: Guanyuan (ren [RN]4), Qihai (RN6), Guilai (stomach [ST]29), Neiguan (pericardium [PC]6), Xuehai (spleen [SP]10), and Diji (SP8).
At the same time, a special Chinese medical drug (the seed of Caryophyllaceae) was placed on the patient's ear. The following points were used: ear point 55 (Shenmen), ear point 58 (Zigong), ear point 22 (Neifenmi), and ear point 33 (Pizhixia). The seeds remained in place for 2 days and were pressed twice daily for 10 minutes. Three days after ET, all patients received a second acupuncture treatment. The following locations were used: Hegu (large intestine [LI]14), Sanyinjiao (SP6), Zusanli (ST36), Taixi (kidney [KI]3), Taichong (liver [LR]3). In addition, the same ear points were pressed at the opposite ear twice daily. The seeds were removed after 2 days.
In group II, the following acupuncture points were used after ET and again 3 days later: San Jiao [SJ]9 (Sidu), SJ12 (Xiaoluo), gallbladder (GB)31 (Fengshi), GB32 (Zhongdu), and GB34 (Yang ling qua). As in group I, patients received acupuncture treatment for 30 minutes. At the same time, the following ear points were used: ear point 17 (Shangzhi), ear point 14 (Feng si), ear point 8 (Sisheng), and ear point 53 (Jian). Equal numbers of needles were applied to the study and control groups. The placebo acupuncture treatment was designed not to influence fertility.
The primary outcome measure was the clinical pregnancy rate, which was used for sample size calculation. We estimated a required sample size of 110 patients in both groups. This was based on the assumption of a clinical pregnancy rate of 20% in the control group, a minimal detectable difference of clinical pregnancies between study group and control group of 15% at a power of 80% (according to a ± of 20%), and a type I error () of 5%. The sample size calculation assumed a one-sided test situation and was performed with an unconditional exact test (StatXact Version 6; CYTEL Software, Cambridge, MA). Secondary outcome measures were the biochemical and the ongoing pregnancy rates. Student's t-test was performed for comparison of continuous parameters between the study and control groups. Comparison of discrete parameters was made by 2 analysis. A level of significance of 5% was chosen for both tests.
A total of 225 patients with a transfer of at least one embryo was included in the study. All patients were randomized: 116 patients received acupuncture according to the principle of traditional Chinese medicine (group I), and 109 patients received placebo acupuncture (group II). All 225 patients completed the study. No patient was lost to follow-up.
Note: Data are presented as mean ± SD or n. NS = nonsignificant; BMI = body
Dieterle. Acupuncture in IVF/ICSI. Fertil Steril 2006.
Fifty-six clinical pregnancies were confirmed by ultrasound. The clinical characteristics of the patients in both groups are presented in Table 1. There were no significant differences in terms of age, body mass index, duration of infertility, cause of infertility, and number of previous IVF/ ICSI cycles between groups I and II.
Table 2 shows the outcome of IVF/ICSI in both groups. No differences regarding the days of stimulation, the number of FSH units required, and serum E2 concentrations on the day of hCG injection were observed. The number of oocytes, the fertilization rate, and the number of embryos transferred were similar in both groups. The data demonstrate that the implantation rate was significantly higher in group I than in group II (14.2% vs. 5.9%, P.01). Clinical pregnancy and ongoing pregnancy rates per transfer were significantly higher in group I (33.6% and 28.4%, respectively) than in group II (15.6% and 13.8%, P.01).
The experimental event rates and the control event rates, including 90% confidence intervals, are listed in Table 3. The numbers needed to treat are 5.5 for the clinical and 6.8 for the ongoing pregnancy rate.
Thirty-seven patients (group I 19, group II 18) underwent their first IVF/ICSI cycle, 59 patients (group I 29, group II 30) had their second cycle after failing to achieve a pregnancy in their first attempt, and 129 women (group I 68, group II 61) received more than two previous IVF/ICSI cycles (Table 4).
Clinical pregnancy rates and implantation rates declined with an increasing number of treatment cycles. After the first cycle, the clinical pregnancy and implantation rates were 47.4% and 28.9%, respectively, in group I, and 33.3% and 11.1% in group II; after the second cycle, 34.5% and 15.2% in group I and 23.3% and 8.6% in group II. After three or more cycles, the clinical pregnancy rate was 29.4% in group I and 8.2% in group II (P.01), and the implantation rate was 12.6% in group I and 3.2% in group II (P.01).
The physiologic mechanisms and clinical significance of acupuncture have not been completely revealed and have been the subject of controversy (10). Recent studies support the concept that acupuncture activates endogenous opioids in
Note: Data are presented as mean ± SD or n. NS nonsignificant.
Dieterle. Acupuncture in IVF/ICSI. Fertil Steril 2006.
Data are presented as experimental event rate (group I) or control event rate (group II), with 95% confidence interval in parentheses.
Dieterle. Acupuncture in IVF/ICSI. Fertil Steril 2006.
the central nervous system, which inhibit central sympathetic neural outflow (11). Functional magnetic resonance imaging, a technique sensitive to changes in regional blood oxygenation as an index of neuronal activity to map human brain functions, has been used for quantitative studies of the correlation between various acupoints and specific functional areas of the brain (12). Wu et al. (13) characterized a pathway in the hypothalamus and limbic system that might mediate acupuncture. Cho et al. (11) demonstrated a correlation between brain activation and corresponding acupoint stimulation. Acupuncture might change the charge and potential of neurons and the concentrations of electrolytes and neuropeptides, such as ±-endorphin (1, 2, 14). In addition, psychological effects of acupuncture have been demonstrated (15). Acupuncture can activate inhibitory systems in the spinal cord, which results in segmental inhibition of sympathetic outflow (16).
Acupuncture has been used in the treatment of female infertility. Although the mechanism of acupuncture in the treatment of female infertility is unknown, studies have demonstrated its potential impact on the hypothalamic-pituitary- ovarian axis and on the uterus (17, 18).
Successful IVF/ICSI demands optimal endometrial receptivity at the time of embryo implantation. Uterine receptivity is regulated by a number of factors, including uterine perfusion (19). Stener-Victorin et al. (20) demonstrated that acupuncture can reduce the uterine artery blood flow impedance. Ayoubi et al. (7) found that a high uterine contraction frequency in IVF at the time of ET comes from a delayed establishment of uteroquiescence after ovulation in IVF in contrast to the menstrual cycle. Fanchin et al. (21) showed that pregnancy rates are affected by uterine contractions at the time of ET. Kim et al. (18) demonstrated that acupuncture of acupoint LI14 can inhibit uterus motility.
Stener-Victorin et al. (22) compared electro-acupuncture analgesia with standard analgesia during oocyte aspiration. Implantation and "take-home baby" rates were significantly higher with electro-acupuncture than without. Paulus et al. (8) compared a group of 80 patients with acupuncture before and after ET with a control group of 80 patients without acupuncture. They found a significantly higher pregnancy rate in the acupuncture group than in the control group.
Infertility can cause stress, leading to a release of stress hormones. It has been suggested that stress reduction might improve fertility (23). Verhaak et al. (24) reported that differences in the emotional status between pregnant and nonpregnant women were present before treatment and became more apparent after the first IVF and ICSI cycle. Women who became pregnant showed lower levels of depression than those who did not. The use of acupuncture to reduce anxiety and stress, possibly through its sympathoinhibitory property and impact on ±-endorphin levels, has been
Dieterle. Acupuncture in IVF/ICSI. Fertil Steril 2006.
reviewed (25). Middlekauff (26) found that sympathetic activation during acute mental stress was eliminated after acupuncture.
When evaluating this study, it has to be considered that the pregnancy rates are affected by the German Embryo Protection Law. This law prohibits embryo selection. A maximum number of three oocytes in the pronuclear stage is allowed to develop and to be transferred. In addition, the mean age of 35.1 years in group I and 34.7 years in group II had an influence on the pregnancy rates. According to the German IVF/ICSI register (2003), the average clinical pregnancy rates for this age are 24.6% for IVF and 22.6% for ICSI. To minimize psychological effects, placebo acupuncture was used in the control group, which was designed not to influence fertility. However, it cannot be completely excluded that placebo acupuncture had an adverse effect on the pregnancy rate.
The results of this study support the significance of acupuncture for the outcome of IVF/ICSI. Even if further evidence has to be accumulated, acupuncture might be a complementary option for patients undergoing IVF/ICSI.
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Acupuncture Normalizes Dysfunction of Hypothalamic-Pituitary-Ovarian Axis By Bo-Ying Chen M.D. Professor of Neurobiology
Institute of Acupuncture and Department of Neurobiology
Shanghai Medical University, Shanghai 200032, P.R. China
(Received June 3, 1997; Accepted with revisions June 30,1997)
This article summarizes the studies of the mechanism of electroacupuncture (EA) in the regulation of the abnormal function of hypothalamic pituitary-ovarian axis (HPOA) in our laboratory. Clinical observation showed that EA with the effective acupoints could cure some anovulatory patients in a highly effective rate and the experimental results suggested that EA might regulate the dysfunction of HPOA in several ways, which rneans EA could influence some gene expression of brain, thereby, normalizing secretion of some hormones, such as GnRH, LH and E2. The effects of EA might possess a relative specificity on acupoints.
KEY WORDS: Electroacupuncture, ß-Endorphin, GnRH, LH, Estradiol, Estrogen receptor, Ovariectomized rat, Hypothalamic-pituitary-ovarian axis
Acupuncture is a treasure of Chinese traditional medicine, which is employed in the treatment of different diseases, especially in relief of all kinds of pain [1, 2] over the world. Since 1960s we have used acupuncture with appropriate electro-stimulation to cure patients with anovulation disorder (sterility), the rate of EA induction of ovulation was increased from 50% initially to 80% presently. Other authors in China also reported that acupuncture was successfully to treat patients with sterility  and the lying-in woman with subnormal contraction of uterus . All the above research demonstrates that acupuncture may be an effective curative method of some woman's diseases. However, many questions, such as "why", "how to" and "which" about the mechanism of EA effect are unknown. To address these problems we supposed that EA might influence the production and secretion of hormones, neurotransmitters or neuro-modulators of HPOA leading to the normalization of hormone status. We also noticed certain artides reported that EA might affect the blood levels of LH, FSH, estradiol (E2) and prolactin in the female patients [4, 5, 6] and EA may be related to long term changes in gene expression [7, 8]. These results are all significant, yet insufficient to explain the mechanism of EA in the regulation of the function of HPOA. To obtain more data, a series of experimental studies in human and animal models has been performed in our laboratory.
MATERIALS AND METHODS
Selection and treatment of cases
Ten cases of chronically anovulatatory patients including eight cases of polycystic ovarian disease (POCA), one case of hypogonadotropic amenorrhoea and one case of oligomenorrhea were treated with EA in 13 menstruation cycles. They were all of productive age and the courses of disease were 3 to 12 years. On the 10th day of each menstruation cycle, the patients accepted the EA treatment. "Guanyuan(RN4)," "Zhongji(RN3)," "Sanyinjiao(SP6)," and bilateral "Zigong(EXCA1)" points were stimulated for 30 min at 8:00 AM, Q.D. for 3 days. The stimulation parameters were 7-8mA and 4-5 Hz with G6805 model generator. The electric current of EA was bearable well for every patient. The blood samples were collected from forearm of the patients one time per 15 min for detection of FSH.LH and ß-endorphin (ß-E).
Five health volunteers of a productive age with normal menstruation cycle were selected as controls, which were undergone the same treatment as above mentioned.
Animals and treatments
Wistar female rats weighting 200-250g were used. The half of animals were undergone ovariectomy and fed in the same environment with the intact rats at least for 15 days and vaginal smears were examined per day for 3 times. No exfoliative epithelium cell was found in the smears as an index for successfill ovariectomy. The ovariectomized rats and intact rats were randomly divided into two groups respectively: ovariectomized rat group (OVX), ovariectomized rat accepted EA treatment group (OVX+EA), intact rat group (INT) and intact rat accepted EA treatment group (INT+EA). The animals in OVX+EA and INT+EA received EA at the experimental acupoints of Guanyuan (RN4), Zhongji (RN3), Sanyinjiao (SP6) and bilateral Zigong (EXCA1) by EA apparatus (Model G6805-2, SMIF, Shanghai, China) with the frequency of 3 Hz and an intensity to produce a slight twitch of the limbs. After 3 days' treatment animals were given EA at Waiguan (SJ5) and Huatuojiaji (EXTRA21) as the control acupoints in the same way (Fig 1). By the end of last experiment, animals were sacrificed and their adrenals, brains and pituitaries were taken out for detection of nucleolar oganizer regions (AgNORs) and hormones.
Pushpull perfusion in hypothalamic preoptic area (POA) and elution of pituitary and LH and ß-endorphin (ß-EP)
The technique of brain pushpull perfusion was processed as previously described by our laboratory . The perfusate from hypothalamic POA was kept at -70°C for GnRX and ß-EP RIA.
The pituitaries were retrieved and put into 4°C cooled saline. Afterward, each pituitary was homogenized with 500µl of 70% acetone aqueous solution at 4°C. The homogenate was centrifugalized (2,000xg for 15 min at 4°C) and the supernatant was freeze-dried for LH and ß-EP RIA.
Radioimmunoassay (RIA) of hormones GnRH IRA: GnRH content in the perfusate from rat hypothalamus was determined by RIA method developed by Nett in 1973 . GnRH was iodinated by the modified chlomine-T technique. Na125 I was manufactured by Radiochemical Center, Amersham.
ß-EP RIA: The sensitive radioimmunoassay was a routine in our laboratory . The standards of human and rat ß-EP was synthesized by Peninsula Laboratories, Inc. and the rabbit antiserum of both ß-EP was developed in our laboratory. The cross-reaction from human ß-EP and camel ß-EP was detected about 20%. The sensitivity of this method was 10pg/tube.
LH, E2 and corticosterone RIA: LH, E2 and corticosterone RIA kits were bought from Shanghai Institute of Biologic Products, the Ministry of Health, P.R. China. All procedures of RIA were performed as described in the kit manuals.
Fig. 1 A: Sketch of ventral view (left) and dorsal view (right) of rat shows the acupoints we used
B:Diagram shows the electroacupuncture procedures in conscious rat
Staining techniques: Vaginal smears were fixed by 100% ethyl alcohol, then stained with HE method. Adrenal sections were cut in 4µm thickness from paraffin blocks and processed with silver nitrate staining technique. In each case, one hundred cells in zona fascicula were examined randomly under 100-fold oil immersion lens. Numbers and sizes of AgNOR dots were counted and measured.
C-fos protein immunohistochemistry: The inmunohistochemical analysis of c-fos expression in rat brain was perforrned as previously described.
Estrogen receptor (ER) protein immunohistochemistry (ABC method): Under sodium pentobarbital anesthesia (50 mg/kg, ip), the animals were perfused via left cardiac ventricle with 100ml of phosphate-buffered saline (PBS), followed by 300ml ice-cold fixative containing 4% paraformaldehyde in 0.1 M phosphate buffer (pH7.4). Afterwards, brain was removed with the same fixative for one day and immersed in 0. lM phosphate buffer containing 30% sucrose for another day. The hypothalamus blocks were frozen with dry ice and cut into 35 µM thick section by cryostat. The brain sections were washed with 0.01M PBS for 15min x 3 and incubated in 0.01M PBS containing 0.5% Triton 100 and 3% normal goat serum (NGS) at 37°C-for one hour. Afterwards, the sections incubated in 1:1,000 ER monoclonal antibody (H222, Abott Co.) at 37°C for one hour, then at 4°C for two days. The sections, washed in PBS three times, were processed by ABC kit (from Vecot Labs) induding sequential incubation at 20°C in the following solutions with washes between them. (1). second antibody (dilution 1:100), 30min. (2). A+B reagents (dilutionl:100), 60min. (3). 0.05% diaminobenzidine/ 0.02% hydrogen peroxide in 0.1M Tris- HCI buffer (pH 7.2) 10min. The sections were washed in tap water, mounted and examined under light microscope. The certain areas of typical immunoreactive positive neurons were measured by computer image analysis system (Vecta PC).
ER mRNA hybridization: The total mRNA of brain was eluted by the modified phenol method . ER cDNA probe (244bp) was labeled by the DlG-labeling kit (from Bohringman Co., Germany). The dot blot hybridization was processed as the method described by Sambrook J and his colleagues . The dot blot images were analyzed with gray density by computer imaging analysis software (TJTY-300, from Tong -Ji university, Shanghai, China).
Statistics: All data in this paper were treated with analysis of variation (ANOVA), least significant difference (ISD) or student T-test.
Effect of EA on ovulatary induction and curing sterility in woman
After EA the blood ß-EP level of the patients resulting in ovulation either declined or maintain at the levels within the range of the normal levels and the ß-EP levels of those failing to show ovulation were significantly higher than the normal's' (table 1). On the other hand, the blood LH and FSH levels of the patients with ovulation after EA treatment tended to be the normal .
The values in this table are mean±SE, *P<0.05
Effect of EA on dysfunction of HPOA in ovariectomized rats For a further study of the mechanism of EA effect on HPOA a series of experiments in the animal models was performed.
(1). EA induces maturation and exfoliation of vaginal epithelium cell and enhances blood level of E2.
After ovariectomy two weeks late, the exfoliated epithelium cell disappeared from the vaginal smears of the rats, but it reappeared in the smears following EA treatment. The blood level of E2 in OVX was increased significantly (table 2). No obvious change was seen in INT after EA treatment and in OVX following EA treatment with the control acupoints.
*P < 0.05 compared with INT, **P<0.01 compared with before EA
(2). EA promotes enlargement of adrenals and enhances activity of adrenal AgNORs as well as blood level of corticosterone
We found the adrenals of OVX+EA were enlarged and the weight of the adrenals was raised significantly. Using histochemical method, the AgNORs of the cells in inner adrenal cortex were examined. The result shows that the activity of AgNORs of OVX was enhanced (table 3, 4), and the level of blood corticosterone in OVX+EA was also increased (table 5). There were no similar effects in INT following EA treatment and in OVX after EA with control acupoints.
(3). EA decreases the level of hypothalamic GnRH, pituitary LH and increases the contents of hypothalamic and pituitary ß-endorphin
After EA treatment the levels of GnRH released from hypothalamus was rnarkedly decreased however, the ß-endorphin (ß-EP) secretion in hypothalamus was raised. The pituitary content of LH was also fallen, but the ß-EP of pituitary was increased, as well as peripheral LH and ß-EP level (Fig.2).
Fig. 2 Change of hypothalarnic GnRH and ß-EP, pituitary LH and ß-EP, blood LH and ß-EP before and after EA
Effect of EA on brain c-fos expression in ovariectomized rats
The area occupied by FOS protein labeled neuron was detected in medial preoptic nucleus (MPN), lateral preoptic nucleus (LPN), suprachiasmatic nucleus (SCN), paraventricular nucleus of the hypothalamus (PAVN), medial amygdala nucleus (MAN), periventricular nucleus of the hypothaLsmus (PVN), ventromedial nucleus of the hypothalamus (VNH) and arcuate nucleus (AR) 4 hours after ovariectomy (fig. 3a). The C-fos immunoreactive labeled neurons disappeared two weeks later following ovariectomy. The rats recovering for more than two weeks after ovariectomy, were received EA treatment. Many specific FOS labeled cells were observed in LPN, VNH, SCN and especially in POA, ARN, and PVN, but not any labeled neuron could be found in MAN. No obvious C-fos expression was shown in those nuclei in INT and INT+EA (fig. 3b).
Fig. 3a C-fos immunocytochemistry neurons distribution after ovariectomy
Fig. 3b C-fos expression labeled neurons following electroacupuncture
Effect of EA on expression of ER protein and ER mRNA in rat brain Estrogen receptor (ER) immunoreactive neurons were observed widely in rat brain with immunohistochemical technique, especially in MPN, ARN and VNH. The above nuclei were measured by computer image analysis system, and the results show that the mean gray density in OVX+EA was decreased apparently compared with that in OVX. Whereas there were no obvious changes of gray density levels in INT and INT+EA (fig, 4).
Fig. 4 Effect of EA on expression of ER protein in rat brain (Immunohistochernistry of monoclonal antibody) *p < 0.01 compared with OVX
The dot blot indicated that ER mRNA expression was increased about 48.11% in OVX compared with INT. The gray density of OVX was 129.75 ± l2.l3 and that in OVX+EA was 199.25 ± 5.75 attenuated significantly (Fig. 5). The gray density level in INT was 87.60 ± 5.91, and the level in INT+EA was 83.60 ± 4.83. There was no significant difference between INT and INT+EA
Fig. 5 Effect of EA on expression of ER mRNA in rat brain (dot blot) *** p < 0.01 compared with OVX
Since 1985 we have observed that the effect of EA ovulatary induction might relate to the hand skin temperature (HST) and the blood level of ß-EP . On the other hand, after EA the blood FSH and LH levels of the patients who successfully ovulated either declined or maintained at normal. In general, provided that body temperature was normal and the environmental temperature was constant round 25°C, the HST may reflect the state of sympathetic system of a patient. These results suggest that in anovulatary cases the hyperactive sympathetic system can be depressed by EA and the function of HPOA can be regulated by EA through central sympathetic system. Moreover, EA may mediate the abnormal function via the influence on the secretion of the hormones in the different Level of HPOA.
To gain more evidences, we designed some animal experiments to explain the mechanism of EA effects on HPOA at the whole, cellular and molecular levels. We found that EA can induce maturation and exfoliation of vaginal epithelium cell in OVX rat. It is known that maturation and exfoliation of vaginal epithelium cells are a reaction dependent on estrogen level. So we determined the level of blood E2 in OVX and OVX+EA. The result shows the level of blood E2 in OVX was lower than that in normal, but it was increased significantly after OVX accepted EA treatment with the experimental acupoints. This result suggests EA might promote the activity of the compensative mechanism to elevate the subnormal level of E2 induced by ovariectomy in rats.
What is this compensative mechanism? To resolve this question, we considered that adrenal is the main organ to secrete sexual hormones except ovarian in females and observed the adrenals of the animals in four groups. The results show that the mean weight of the adrenal in OVX+EA was higher than that in OVX, INT and INT+EA, suggesting the adrenal function might be activated by EA. Subsequently, we detected that the number of AgNORs in zona fasciculata of OVX+EA was significantly increased. Nucleolar organizer regions (NORs) are loops of DNA, which possess ribosomal RNA (rRNA) genes. They are of vital significance in the ultimate synthesis of protein. Thus, the number and configuration of AgNORs (NORs stained by silver staining method) may reflect the activity of cell differentiation and transcription of nucleolar rDNA . In the same time we found the content of blood corticosterone in OVX+EA was raised markedly, but there was no change of blood corticosterone in OVX, INT and INT+EA. This result provided a further evidence that the adrenal cortex cells were initiated in OVX+EA.
The results including the changes of GnRH releasing from hypothalamus and of the pituitary and blood LH contents suggest that the effects of acupuncture in the regulation of HPOA may be exerted via to promote the function of hypothalamic pituitary-adrenal axis (HPAA), increasing the synthesis and secretion of adrenal steroid horrnones, the androgen of which then be transformed into estrogen in other tissues and thereby reset the negative feedback of estrogen to HPOA. Moreover, EA may accelerate the release of brain and pituitary ß-EP to inhibit the overnormal secretion of GnRH and LH that may be normalized.
Recently immunohistochemical analysis of the expression of oncogene c-fos ABl was induced by variety of stimuli [16, 17]. This represents a new method for mapping neuronal activity at the cellular level  and thus functionally and systematically tracing neuronal pathway in the nervous system (C NS) . We used this method to examine the distribution of FOS labeled neuron in CNS for recovery of more evidences that EA may alter the neuroendocrine function of HPOA in ovariectomized rats in cellular and gene level. The results show that the specific FOS labeled neurons were observed especially in POA, ARN and PVN in OVX following EA treatment. In above nuclei there were a high concentration of GnRH and ß-EP neuron . These results suggest this fact that the expression of FOS labeled neurons reappeared in above mentioned areas following EA treatment in ovariectomized rats may be related to the changes of GnRH and ß-EP from rat hypothalamus after EA treatment.
The level of estrogen in the body may regulate the expression of ER, which may by down-regulated following increase of estrogen level and up-regulated after decrease of estrogen . Our finding that after decline of blood E2 induced by ovariectomy the expression of ER was increased and the expression of ER was inhibited by EA inducing the elevation of blood E2 are in accordance with these reported results. ER existing in the brain, especially in POA, ARN and VHN may mediate the function of neuroendocrine system [22, 23]. Thus, our observations suggest that the influence of EA on the change of ER expression in brain may be one of further mechanisms of EA normalizing the dysfunction of HPOA.
INT rats as experimental control we adopted were all of in the stage of preestrus and estrus because the animal sexual hormes and brain ER expressions were changed with the sexual cycle . All INT rats were selected to fix in the two stages there may be a relative constant comparability.
Our results show no same effects were seen after EA treatment in INT and following EA with control acupoints in OVX, suggesting that EA may possess a relative specificity on acupoint and the effect of EA may be a kind of normalization.
Our observations reveal that acupuncture may regulate the abnormal function of HPOA in many ways, which means that acupuncture may activate C-fos expression of brain, then a long term changes at molecular level would start, following the regulation of gene expression in FOS relative gene, such as ER mRNA and GnRH mRNA involved. On the other hand, EA may promote the activity of the body compensative mechanisms, then the levels of hormones, such as GnRH, LH, estrogen and so on would be normalized. The effect of acupuncture on regulating the function of HPOA may possess a relative specificity of acupoint. Moreover, our clinical and animal experimental results suggest that it is necessary for obtaining a satisfactory effect that proper stimulation should be about thirty minutes Q.D. for three days. This suggestion provides a successful consideration for clinical practice in curing the woman patients with dysfunction of sexual endocrine, such as primary ovarian dysfunction, climacteric syndrom, after-ovariectomy and polycystic ovarian disease etc.
The work was supported by National Natural Foundation of China (3880910 and 392708340) and a grant from the State Key Laboratory of Medical Neurobiology of China (92003).
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