Treatment For Infertile Women Undergoing Intracytoplasmic Sperm injection
Sandra L. Emmons, MD
Phillip Patton, MD
Background Little information exists regarding the use of acupuncture
in combination with allopathic treatment of infertility.
Objective To describe the use of acupuncture to stimulate follicle
development in women undergoing in vitro fertilization.
Design, Setting, and Patients Prospective case series of 6 women
receiving intracytoplasmic sperm injection and acupuncture along with
agents for ovarian stimulation.
Main Outcome Measures Number of follicles retrieved, conception,
and pregnancy past the 1st trimester before and after acupuncture treatment.
Results No pregnancies occurred in the non-acupuncture cycles.
Three women produced more follicles with acupuncture treatment (mean,
11.3 vs 3.9 prior to acupuncture; P=.005). All 3 women conceived, but
only 1 pregnancy lasted past the 1st trimester.
Conclusion Acupuncture may be a useful adjunct to gonadotropin
therapy to produce follicles in women undergoing in vitro fertilization.
Female Infertility, Intracytoplasmic Sperm Injection, In Vitro Fertilization,
Infertility is an area of women's health that has sparked much consumer
interest in acupuncture. However, there is little published information
concerning the combination of acupuncture with allopathic infertility
We present results from 6 women treated with acupuncture to enhance
follicle development during in vitro fertilization with intracytoplasmic
sperm injection (ICSI) cycles. Our patients all had
difficulty with follicle production despite maximum gonadotro-pin therapy. They were referred for acupuncture as a last resort. We
compare results for the acupuncture cycle with results previous to acupuncture.
The methods used for ovarian hyperstimulation have been described.1
Briefly, ovarian hyperstimulation was achieved using a long-acting gonadotropin-releasing
hormone agonist (Lupron, TAP Pharmaceuticals Inc, Deerfield, Ill) administered
either in the mid-luteal phase or following a minimum of 2 weeks of
oral contraceptive treatment. After biochemical evidence of pituitary
suppression (serum estradiol <40 pg/mL), subcutaneous follicle-stimulating
hormone was given twice daily (3-6 amps/d). Follicular response was
monitored with serial pelvic ultrasonography and serum estradiol measurements.
When at least 2 follicles were >17 mm, 7500 IU of human chorionic
gonadotropin was given intramuscularly, and transvaginal ultrasound-directed
oocyte retrieval was scheduled 36 hours later. Oocytes were identified
and then rinsed free of follicular fluid, blood, and debris in TALP-Hepes
plus 10% serum substitute supplement (SSS) before being placed in 0.9
mL of bicarbonate-buffered human tubal fluid (HTF) medium plus 10% SSS.2
Spermatozoa were prepared using a discontinuous Percoll gradient. Oocytes
for injection were denuded of cumulus cells using hyaluronidase followed
by mechanical removal and then assessment for maturity. Metaphase II
oocytes were injected with a single immobilized sperm.
Following ICSI, oocytes were cultured in 0.9 mL of HTF plus 10% SSS
in organ culture dishes and housed in individually gassed chambers at
37ºC with 5% CO2, 5% O2, and 90% N2. At 15-18 hours following insemination,
oocytes were assessed for pronuclei as evidence of fertilization. On
the morning of day 3, cleaving embryos were transferred to 50-µL
drops of S2 (Scandinavian IVF Sciences, Gothenburg, Sweden) under oil.
Embryos of similar quality were grouped together. Embryos cultured beyond
day 5 were transferred to fresh medium.
Luteal support consisted of intravaginal progesterone (300 mg/d) beginning
on the day following embryo transfer in combination with 1500 IU of
hCG intramuscularly given 5 days after oocyte retrieval. Embryo transfer
was performed on day 5 or 6 of extended culture using a Soft-Pass catheter
(Cook Ob-Gyn, Bloomington, Ind).
The women began acupuncture treatment at the same time that they began
follicle-stimulating hormone injections. They had 3 or 4 twice-weekly
treatments, on days 1-3, 4-6, 7-9 and in some cases 9-11, with the final treatment on the day of or prior to egg retrieval.
Acupuncture treatments were aimed at stimulating Ming Men (BL 23, GV
4), Chong Mo, and Ren Mo. Points BL 23 and GV 4 were used at all treatments,
whereas the Chong Mo (SP 4, MH 6) and Jenn Mo (KI 6, LU 7) Master and
Couple points were alternated. Additional points were added on an individual
basis, including LR 3, CV 4, 6, SP 30, BL 18, 20, 60, and 62.
Main outcome measures included the number of follicles retrieved, the
incidence of pregnancy, and pregnancy lasting past the 1st trimester.
Statistical analyses were calculated using SPSS version 10 (SPSS Inc,
Results are shown in Table
1. None of the women achieved pregnancy during the non-acupuncture
cycles. Three of the women (patients 1-3) clearly recruited more follicles
with acupuncture than prior to acupuncture. For the 3 who responded,
the mean number of follicles with acupuncture was 11.3 vs 3.9 prior
to acupuncture (P=.005). All 3 achieved chemical pregnancy, but only
1 continued the pregnancy past the 1st trimester.
Patient 4 recruited fewer follicles during the acupuncture cycle than
during previous cycles. Patients 5 and 6 recruited more follicles with
acupuncture, but still recruited few follicles (P=.13). Patient 6 did
achieve a chemical pregnancy, whereas patient 5 had the retrieval cancelled
due to too few follicles.
On average, significantly more follicles were recruited with acupuncture
than without (P=.02). Data on estrogen levels and endometrial lining
thickness were not routinely collected in all cycles. For the 4 women
(patients 1, 3, 4, and 5) who had estradiol levels measured during both
acupuncture and non-acupuncture cycles, mean estradiol levels were higher
during the acupuncture cycles than the non-acupuncture cycles (mean
[SD], 1471  pg/mL for acupuncture vs 731  pg/mL for non-acupuncture),
but this finding did not reach statistical significance (P=.08). Three
women (patients 1, 3, and 6) had endometrial lining measurements recorded
for both acupuncture and non-acupuncture cycles. The difference in average
endometrial lining thickness, measured on the day of follicle retrieval,
did not approach statistical significance (acupuncture, 10.4 [2.2] mm
vs non-acupuncture, 12.1 [1.1] mm, P=.33).
None of the 6 women reported any adverse reaction to the acupuncture
treatments. There were no adverse reactions from the follicle retrievals
or embryo transfers during either acupuncture or non-acupuncture cycles.
|Table 1. Outcomes for Acupuncture
vs Non-Acupuncture Cycles Among 6 Women Undergoing ICSI*
|*ICSI indicates intracytoplasmic sperm injection;
IUP, intrauterine pregnancy; and SAB, early spontaneous abortion.
P=.02 for overall acupuncture follicles vs non-acupuncture follicles.
Our findings suggest that acupuncture may be a useful adjuvant to gonadotropin
therapy among women undergoing ICSI. In this context, acupuncture increased
the number of follicles produced and appeared to also increase the estradiol
level, but did not appear to affect endometrial lining thickness. However,
none of the women in this report had difficulty with achieving adequate
Although there is significant consumer interest in using alternative
and complementary therapies for infertility, there is little research
that addresses the combination of techniques. Stener-Victorin et al3
published a report of using acupuncture to decrease the uterine pulsatility
index among women with a history of poor uterine lining response to
in vitro fertilization. They demonstrated a significant decrease in
uterine pulsatility index, which was maintained for 2 weeks, by using
4 set acupuncture points with electric stimulation. Gerhard and Postneek4
published results of infertile women treated with acupuncture vs similar
women treated hormonally, and showed a similar pregnancy rate among
the 2 groups. Siterman et al5 showed improvement in sperm quality among
subfertile men treated with acupuncture.
The mechanisms responsible for the systemic actions of acupuncture have
been debated but not yet clearly defined. Traditional Chinese Medicine
(TCM) speaks to increasing and harmonizing Qi within the reproductive
organs.6 Scientific analysis of acupuncture used in the context of pain
syndromes has shown acupuncture to raise the level of endogenous opiates7
and to decrease the level of sympathetic nerve stimulation8 at the painful
area. The decrease in sympathetic stimulation may be 1 of the factors
that results in an increased level of blood flow to the area.7,8 In
the context of infertility, acupuncture may be helpful by increasing
blood supply to the reproductive organs, or may simply increase relaxation
or reduce subjective stress surrounding the infertility diagnosis and
These cases have an obvious bias. The group was selected from those
who responded poorly to gonadotropin therapy. The patients served as
their own historical controls, but there was no similar group that simply
had another ICSI attempt without acupuncture to compare before and after
results. The acupuncture treatments were not standardized. Even though
similar points were chosen for all women, points based on the individual
TCM diagnosis were also used.
The cases do present evidence that a structured clinical trial of acupuncture
to assist in follicle development for women undergoing in vitro fertilization
and/or ICSI would be of interest. Many women undergoing infertility
treatment seek alternative care; knowing the interaction of these 2
systems would be most useful.
1. Patton PE, Eaton D, Burry KA, Wolf DP. The use of gonadotropin-releasing
hormone agonist to regulate oocyte retrieval time. Fertil Steril. 1990;
2. Bavister BD, Boatman DE, Leibfried L, Loose M, Vernon MW.
Fertilization and cleavage of rhesus monkey oocytes in vitro. Biol Reprod.
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;11:1314-1317.
4. Gerhard I, Postneek F. Auricular acupuncture in the treatment
of female infertility. Gynecol Endocrinol. 1992;6:171-181.
5. Siterman S, Eltes F, Wolfson V, Zabludovsky N, Bartoov B.
Effect of acupuncture on sperm parameters of males suffering from subfertility
related to low sperm quality. Arch Androl. 1997;39:155-161.
6. Vincent CA, Richardson PH. The evaluation of therapeutic acupuncture:
concepts and methods. Pain. 1986;24:1-13.
7. Andersson S, Lundeberg T. Acupuncture: from empiricism to
science: functional background to acupuncture effects in pain and disease.
Med Hypotheses. 1995;45:271-281.
8. Cai W. Acupuncture and the nervous system. Am J Chin Med.
1992; 20: 331-337.
Dr Sandra Emmons is an Assistant Professor of Obstetrics and Gynecology
at Oregon Health Sciences University. Dr Emmons practices Obstetrics
and Gynecology, and incorporates Medical Acupuncture in her practice.
She is a Fellow of the American Academy of Obstetrics and Gynecology.
Sandra L. Emmons,
Assistant Professor, Obstetrics and Gynecology
3181 SW Sam Jackson Park Rd
Portland, OR 97201
Dr Phillip Patton
is an Associate Professor of Obstetrics and Gynecology at Oregon Health
Sciences University with specialty boards in Reproductive Endocrinology.
Dr Patton's practice at OHSU emphasizes infertility and assisted reproductive
technology, and he is a Fellow of the American Academy of Obstetrics