Diagnostic indications of subfertility
Infertility is broadly defined as either an inability to conceive after one or one-two years of frequent unprotected sexual intercourse.
Frequent unprotected sexual intercourse should occur at regular intervals at one to three days in the woman’s fertile window.
However, the more frequent unprotected sexual intercourse is (every one-two days), the more likely it is to result in a conception. There are other important considerations, for example aging fertility, and or stress may negatively influence time to conception.
Reasons for utilization of assisted reproductive technology
In the UK male factor subfertility is the most prevalent condition leading to the use of assisted reproductive technology. The next is interestingly, unexplained subfertility, i.e. non-medically identified. There are other less prevalent conditions where assisted reproductive technology is utilized, tubal factor disease, in some cases of endometriosis or hormonal disorders.
Medical fertility treatment failure
There may be circumstances where assisted reproduction fails at a certain treatment event, a few general examples include during ovarian stimulation, during embryonic development or after the transfer of embryo(s) or blastocyst(s) into a woman’s uterus. The reason fertility treatment fails during any of these phases may be due to factors that are known and in particular cases the reasons may be considered unknown with various other usually non-evidenced based approaches offered. In some cases there is the reasoning that IVF outcome results from cumulative attempts, which is debatable. If fertility treatment fails frequently post transfer this situation may be classified as recurrent implantation failure (RIF) and advanced tests, and innovative investigation and treatments may be tried.
It is important to note that we work with clients that are preparing for their first or second In Vitro Fertilization (IVF)/Intracytoplasmic Sperm Injection (ICSI) cycle, as well as with clients that have complicated reproductive treatment histories and RIF.
We provide a specialist and advanced acupuncture service to help couples trying to conceive naturally or for couples that are undergoing assisted reproductive technology (including IVF/ICSI, Frozen Transfer (FT), third party sperm donor or egg donor cycles).
We also work with women that are having ovulation induction usually over a 3-month period. However, intrauterine insemination (IUI) has become less utilized over the recent years. Gamete Intra-Fallopian Transfer (GIFT) is rarely utilized as an assisted reproductive technology for couples - so we do work less in comparison with patients undergoing these technologies.
Probable mechanisms of acupuncture
It has been scientifically hypothesised that the mechanisms by which acupuncture may work are due to:
- regulation of fertility hormones, FSH, oestrogen and progesterone;
- supporting follicle receptor expression, egg production and modifying the quality of eggs;
- improving blood flow to the reproductive system effecting the endometrial lining, promoting implantation;
- enhancing luteal function.
Acupuncture helps women feel less anxious, and stressed about their difficulty conceiving, medical fertility treatment processes or their experience of fertility treatment obstacles. Acupuncture treatment management that reduces levels of anxiety and stress may positively help the reproductive system, pregnancy and live birth rate outcomes.
Our fertility acupuncture specialist Lianne Aquilina has conducted work in the area of the psychological impact of subfertility and fertility treatment and uses acupuncture to help to reduce fertility related anxiety, stress and depression, especially for the women that request support.
However, it is important to note, the above explanations how acupuncture may work are based on mainstream perspective of health and illness. From another perspective acupuncture is believed to act in various ways that promote a correct internal environment through its own unique and elaborate system. Many of you may already be familiar with concepts Yin Yang, and the flow and quality of Qi. Although, it has to be said traditional acupuncturists are far from collating sufficient evidence that encompasses epidemiology, diagnosis, pathology and measuring illness within its own paradigm.
Current research issues
With regards to the existing scientific evidence base of acupuncture alongside IVF there is now a recognized need for good, preferably high quality randomized controlled trials i.e. consisting of adequate research design and methodology. For example a systematic review of twenty randomized controlled trials found that trials of acupuncture adjunct to assisted reproductive technology were all of low methodological quality. An example of this is many trials (16/20) were classified as having “unclear risks,” of allocation bias. Proper randomization methods eliminate selection bias and allow an appropriate statistical analysis of either the effectiveness or ineffectiveness of an (hopefully well designed) intervention.
Women in these research trials had limited acupuncture treatment management, with no diagnosis by their acupuncturist. Acupuncture treatment consisted of one-three sessions, at an advanced stage of their medical fertility treatment. In other words, no acupuncture treatments were administered in preparation for assisted reproductive technology or during pretreatment (down regulation). Acupuncture treatment should be frequently administered during ovarian stimulation – as acupuncture has been hypothesized to benefit several important processes regarding folliculogenesis and egg maturity. These factors are congruent to prior events necessary for implantation.
Timing of acupuncture
Thus, research to date is largely focused on acupuncture at the point of the transfer of an already developing embryo. This is why several researchers, including myself, describe (aside from other design and methodological issues) that the acupuncture intervention has been, lets say, ineffective or minimally effective and poorly designed.
A full critique of acupuncture research is beyond the scope of this blog, and requires a separate academic paper. Yet, a few notes can be made. We already understand from the scientific literature that acupuncture should be compared with usual care rather than controversial placebo acupuncture techniques, particularly when sham acupuncture has been found to provide positive biological effects. We will likely continue to find this to be true. If there is a requirement to look at the effectiveness of acupuncture alongside fertility treatment to improve live birth rate the comparator should be usual care.
A newly designed trial should therefore be of a pragmatic design - where practitioners can administer a well-designed acupuncture intervention as per normal routine care and practice, and allow time for modifications resulting from acupuncture to take place.
To read Lianne's biography click here
To book an appointment with Fertility Acupuncturist Lianne Aquilina BSc Hons MBAcC MSc for acupuncture treatment management click here.
Research recommendations acupuncture for IVF/ICSI
If you would like to know more detailed academic recommendations on how to design and conduct a randomized controlled trial click here. Our specialist has a Master of Science in Applied Health Research and developed and produced a research protocol for a randomized controlled trial.