Meta Analyses and Recent Reviews

Research done on all available studies to determine the effectiveness of a particular treatment on a grand scale.

Conclusion(s)
Acupuncture improves CPR and LBR among women undergoing IVF based on the results of studies that do not include the Streitberger control. The Streitberger control may not be an inactive control. More positive effects from using acupuncture in IVF can be expected if an appropriate control and more reasonable acupuncture programs are used.

Objective
To evaluate the effect of acupuncture on in vitro fertilization (IVF) outcomes.

Design
Systematic review and meta-analysis.

Patient(s)
Women undergoing IVF in randomized controlled trials (RCTs) who were evaluated for the effects of acupuncture on IVF outcomes.

Setting
Not applicable.

Intervention(s)
The intervention groups used manual, electrical, and laser acupuncture techniques. The control groups consisted of no, sham, and placebo acupuncture.

Main Outcome Measure(s)
The major outcomes were clinical pregnancy rate (CPR) and live birth rate (LBR). Heterogeneity of the therapeutic effect was evaluated with a forest plot analysis. Publication bias was assessed by a funnel plot analysis.

Result(s)
Twenty-four trials (a total of 5,807 participants) were included in this review. There were no significant publication biases for most of the comparisons among these studies. The pooled CPR (23 studies) from all of the acupuncture groups was significantly greater than that from all of the control groups, whereas the LBR (6 studies) was not significantly different between the two groups. The results were different when the type of control was examined in a sensitivity analysis. The CPR and LBR differences between the acupuncture and control groups were more obvious when the studies using the Streitberger control were ignored. Similarly, if the underlying effects of the Streitberger control were excluded, the LBR results tended to be significant when the acupuncture was performed around the time of oocyte aspiration or controlled ovarian hyperstimulation.

The authors concluded, “The odds ratio of 1.65 suggests that acupuncture increased the odds of clinical pregnancy by 65% compared with the control groups… In absolute terms 10 patients would need to be treated with acupuncture to bring about one additional clinical pregnancy. These are clinically relevant benefits.”

Impressive as these results are they may still be an underestimate, since the authors included women who’s IVF cycles were cancelled before transfer.

Objective - To evaluate whether acupuncture improves rates of pregnancy and live birth when used as an adjuvant treatment to embryo transfer in women undergoing in vitro fertilisation. Design - Systematic review and meta-analysis.

Data sources - Medline, Cochrane Central, Embase, Chinese Biomedical Database, hand searched abstracts, and reference lists.

Review methods - Eligible studies were randomised controlled trials that compared needle acupuncture administered within one day of embryo transfer with sham acupuncture or no adjuvant treatment, with reported outcomes of at least one of clinical pregnancy, ongoing pregnancy, or live birth. Two reviewers independently agreed on eligibility; assessed methodological quality; and extracted outcome data. For all trials, investigators contributed additional data not included in the original publication (such as live births). Meta-analyses included all randomised patients.

Data synthesis - Seven trials with 1366 women undergoing in vitro fertilisation were included in the meta-analyses. There was little clinical heterogeneity. Trials with sham acupuncture and no adjuvant treatment as controls were pooled for the primary analysis. Complementing the embryo transfer process with acupuncture was associated with significant and clinically relevant improvements in clinical pregnancy (odds ratio 1.65, 95% confidence interval 1.27 to 2.14; number needed to treat (NNT) 10 (7 to 17); seven trials), ongoing pregnancy (1.87, 1.40 to 2.49; NNT 9 (6 to 15); five trials), and live birth (1.91, 1.39 to 2.64; NNT 9 (6 to 17); four trials). Because we were unable to obtain outcome data on live births for three of the included trials, the pooled odds ratio for clinical pregnancy more accurately represents the true combined effect from these trials rather than the odds ratio for live birth.

The results were robust to sensitivity analyses on study validity variables. A prespecified subgroup analysis restricted to the three trials with the higher rates of clinical pregnancy in the control group, however, suggested a smaller non-significant benefit of acupuncture (odds ratio 1.24, 0.86 to 1.77).

Conclusions - Current preliminary evidence suggests that acupuncture given with embryo transfer improves rates of pregnancy and live birth among women undergoing in vitro fertilisation.

Click here for more information on IVF acupuncture in Vancouver, and the IVF Acupuncture Group founder Dr. Spence Pentland

Another group of researchers have analysed updated clinical trial data and have come to the same conclusion as those who published the BMJ meta analysis, namely acupuncture is a useful addition to IVF. It has been published as a Cochrane Review. The Cochrane Collaboration is an international and independent organization dedicated to making up-to-date, accurate information about the effects of healthcare readily available worldwide.

Introduction: Acupuncture has more recently been studied in assisted reproductive treatment, although its role in reproductive medicine is still debated. This is a meta-analysis to determine the effectiveness of acupuncture in the outcomes of assisted reproductive technologies (ART).

Material & Methods: All reports which described randomised controlled trials of acupuncture in assisted conception were obtained through searches via the Menstrual Disorders and Subfertility Group's specialised Register of controlled trials, the OVID MEDLINE (1996 to August 2007), CINAHL- cumulative Index to Nursing & Allied Health Literature (1982 to August 2007), EMBASE (1980 -August 2007), AMED, National research Register, US equivalent Clinical Trials register (http://www.clinicaltrials.gov) were searched using the OVID software, the Chinese literature databases were searched from the China Academic Journal Electronic full text Database in the China National Knowledge Infrastructure and Index to Chinese Periodical Literature.

All relevant references were also hand searched.

The selection criteria included randomised controlled trials of acupuncture that included couples who were undergoing ART and/or acupuncture and compared these treatments to each other, placebo or no treatment for the treatment of primary and secondary infertility were included.

Women with medical illness deemed contraindications for ART or acupuncture were excluded. Quality assessment and data extraction were performed independently by two reviewers.

Meta-analysis was performed using odds ratio for dichotomous outcomes. Subgroup analysis and sensitivity analysis were performed where necessary. The outcome measures were the live birth rate, the clinical, ongoing pregnancy rate, miscarriage rate and any reported side effects of treatment.

Results Thirteen randomised controlled trials were identified that involved acupuncture and assisted conception. Ten trials were included and three were excluded.

Acupuncture on the day of ET improves the ongoing pregnancy rate (Odds Ratio = 1.85; 95% confidence interval 1.18-2.91) and the clinical pregnancy rate (Odds ratio = 1.65; 95% confidence interval 1.22-2.24), but there was no evidence of a difference in the miscarriage rate compared to controls. Acupuncture on the day of ET + 2 to 3 days after ET (repeated acupuncture) improves the clinical pregnancy rate (Odds Ratio = 2.23, 95% CI 1.41 - 3.51) but not the ongoing pregnancy rate (Odds Ratio = 1.93, 95% CI 0.86-4.36). Repeated acupuncture did not affect the miscarriage rate.

Acupuncture around the time of oocyte retrieval has no evidence of benefit over the live birth rate (Odds Ratio 0.84, 95% CI 0.50 - 1.42), ongoing pregnancy (Odds Ratio 0.84, 95% CI 0.5 -1.42), clinical pregnancy (Odds ratio 1.07, 95% CI 0.71-1.61), and miscarriage rate (Odds Ratio 0.59, 95% CI 0.14-2.56).

Conclusions The data from this meta-analysis suggests that acupuncture performed on the day of ET does increase the clinical pregnancy rate of IVF treatment; however, this could be attributed to placebo effect and the small number of patients included. Further larger RCTs are necessary to confirm the results.

Click here for more information on IVF acupuncture in Vancouver, and the IVF Acupuncture Group founder Dr. Spence Pentland

Purpose of review: The present review gives an overview of the potential use of traditional Chinese medicine in the treatment of infertility, including an evidence-based evaluation of its efficacy and tolerance.

Recent findings: Recent studies demonstrated that traditional Chinese medicine could regulate the gonadotropin-releasing hormone to induce ovulation and improve the uterus blood flow and menstrual changes of endometrium.

In addition, it also has impacts on patients with infertility resulting from polycystic ovarian syndrome, anxiety, stress and immunological disorders.

Although study design with adequate sample size and appropriate control for the use of traditional Chinese medicine is not sufficient, the effective studies have already indicated the necessity to explore the possible mechanisms, that is, effective dose, side effect and toxicity of traditional Chinese medicine, in the treatment of infertility by means of prospective randomized control trial.

Summary: The growing popularity of traditional Chinese medicine used alone or in combination with Western medicine highlights the need to examine the pros and cons of both Western and traditional Chinese medicine approaches. Integrating the principle and knowledge from well characterized approaches and quality control of both traditional Chinese medicine and Western medical approaches should become a trend in existing clinical practice and serve as a better methodology for treating infertility.

Click here for more information on IVF acupuncture in Vancouver, and the IVF Acupuncture Group founder Dr. Spence Pentland

Another review of the literature from a group in Hong Kong concludes that the positive effect of acupuncture in the treatment of subfertility may be related to the central sympathetic inhibition by the endorphin system, the change in uterine blood flow and motility, and stress reduction.

OBJECTIVE: To review systematically the use of acupuncture in the management of subfertility.

DESIGN: A computer search was performed via several English and Chinese databases to identify journals relevant to the subject.

RESULT(S): The positive effect of acupuncture in the treatment of subfertility may be related to the central sympathetic inhibition by the endorphin system, the change in uterine blood flow and motility, and stress reduction. Acupuncture may help restore ovulation in patients with polycystic ovary syndrome, although there are not enough randomized studies to validate this.

There is also no sufficient evidence supporting the role of acupuncture in male subfertility, as most of the studies are uncontrolled case reports or case series in which the sample sizes were small. Despite these deficiencies, acupuncture can be considered as an effective alternative for pain relief during oocyte retrieval in patients who cannot tolerate side effects of conscious sedation.

The pregnancy rate of IVF treatment is significantly increased, especially when acupuncture is administered on the day of embryo transfer.

CONCLUSION(S): Although acupuncture has gained increasing popularity in the management of subfertility, its effectiveness has remained controversial.

Click here for more information on IVF acupuncture in Vancouver, and the IVF Acupuncture Group founder Dr. Spence Pentland

A newer version of this data base by the same authors as the one listed above concluded that there is an increase in live birth rate when acupuncture is performed on day of embryo transfer.

Background
Acupuncture has recently been studied in assisted reproductive treatment (ART) although its role in reproductive medicine is still debated.

Objectives
To determine the effectiveness of acupuncture in the outcomes of ART.

Search strategy
All reports which describe randomised controlled trials of acupuncture in assisted conception were obtained through searches of the Menstrual Disorders and Subfertility Group Specialised Register, CENTRAL, Ovid MEDLINE (1996 to August 2007), EMBASE (1980 to August 2007), CINAHL (Cumulative Index to Nursing & Allied Health Literature) (1982 to August 2007), AMED, National Research Register, Clinical Trials register (www.clinicaltrials.gov), and the Chinese database of clinical trials.

Selection criteria
Randomised controlled trials of acupuncture for couples who were undergoing ART comparing acupuncture treatment alone or acupuncture with concurrent ART versus no treatment, placebo or sham acupuncture plus ART for the treatment of primary and secondary infertility. Women with medical illness deemed contraindications for ART or acupuncture were excluded.

Data collection and analysis
Sixteen randomised controlled trials were identified that involved acupuncture and assisted conception. Thirteen trials were included in the review and three were excluded. Quality assessment and data extraction were performed independently by two review authors. Meta-analysis was performed using odds ratio (OR) for dichotomous outcomes. The outcome measures were live birth rate, clinical ongoing pregnancy rate, miscarriage rate, and any reported side effects of treatment.

Main results
There is evidence of benefit when acupuncture is performed on the day of embryo transfer (ET) on the live birth rate (OR 1.86, 95% CI 1.29 to 2.77) but not when it is performed two to three days after ET (OR 1.79, 95% CI 0.93 to 3.44). There is no evidence of benefit on pregnancy outcomes when acupuncture is performed around the time of oocyte retrieval.

Authors' conclusions
Acupuncture performed on the day of ET shows a beneficial effect on the live birth rate; however, with the present evidence this could be attributed to placebo effect and the small number of women included in the trials. Acupuncture should not be offered during the luteal phase in routine clinical practice until further evidence is available from sufficiently powered RCTs.

Plain language summary

Acupuncture and assisted conception
The data from this meta-analysis suggests that acupuncture does increase the live birth rate with in vitro fertilisation (IVF) treatment when performed around the time of embryo transfer. However, this could be attributed to placebo effect and the small number of trials included in the review. Larger studies are necessary to confirm the results. Acupuncture may have potential harmful effects in early pregnancy and hence clinicians should be cautious when giving advice regarding the use of acupuncture in early pregnancy.

Click here for more information on IVF acupuncture in Vancouver, and the IVF Acupuncture Group founder Dr. Spence Pentland

The objectives of this systematic review were to determine the effectiveness of (a) acupuncture and (b) Chinese herbal medicine on the treatment of male and female subfertility by assisted reproductive technologies (ART). All reports from RCTs of acupuncture and/or Chinese herbal medicine in ART were obtained via searches through The Cochrane Menstrual Disorders and Sub-fertility Group's Specialised Register of controlled trials, and other major databases. The outcome measures were determined prior to starting the search, and comprised: live birth rate, ongoing pregnancy rate, clinical pregnancy rate, the incidence of ovarian hyperstimulation syndrome and multiple pregnancy, miscarriage rate and adverse effects arising from treatment. Overall, 14 trials (a total of 2670 subjects) were included in the meta-analysis. The results provided no evidence of benefit in the use of acupuncture during assisted conception. Further studies should attempt to explore the potential placebo, as well as treatment, effects of this complimentary therapy. Essential elements for a quality RCT will be the size of the trial, the use of a standardised acupuncture method and of placebo needles.

Click here for more information on IVF acupuncture in Vancouver, and the IVF Acupuncture Group founder Dr. Spence Pentland

Jane Lyttleton "Finally, a tongue in cheek analysis of meta-analyses, randomised, placebo controlled trials and evidence based medicine. These authors very cleverly make a strong case for the fact that some interventions do NOT lend themselves to randomised blinded trials.But can still have a place in medicine simply because they have been seen to work. While not for a minute purporting to compare an acupuncture treatment to the life saving action of a parachute, we nevertheless would like to point out that there are some aspects of a discipline like acupuncture which will never be able to be squeezed onto the confines of a double blind randomised trial, without losing something of its essence. Other aspects of acupuncture, like some of its known physiological effects, can be measured in a trial setting - however the results of these trials should never be taken to be telling the WHOLE story!"

Objectives To determine whether parachutes are effective in preventing major trauma related to gravitational challenge.

Design Systematic review of randomised controlled trials.

Data sources: Medline, Web of Science, Embase, and the Cochrane Library databases; appropriate internet sites and citation lists.

Study selection: Studies showing the effects of using a parachute during free fall.

Main outcome measure Death or major trauma, defined as an injury severity score > 15.

Results We were unable to identify any randomised controlled trials of parachute intervention.

Conclusions As with many interventions intended to prevent ill health, the effectiveness of parachutes has not been subjected to rigorous evaluation by using randomised controlled trials. Advocates of evidence based medicine have criticised the adoption of interventions evaluated by using only observational data. We think that everyone might benefit if the most radical protagonists of evidence based medicine organised and participated in a double blind, randomised, placebo controlled, crossover trial of the parachute.

They conclude their discussion with a call to arms .......

"Only two options exist. The first is that we accept that, under exceptional circumstances, common sense might be applied when considering the potential risks and benefits of interventions.

The second is that we continue our quest for the holy grail of exclusively evidence based interventions and preclude parachute use outside the context of a properly conducted trial. The dependency we have created in our population may make recruitment of the unenlightened masses to such a trial difficult. If so, we feel assured that those who advocate evidence based medicine and criticise use of interventions that lack an evidence base will not hesitate to demonstrate their commitment by volunteering for a double blind, randomised, placebo controlled, crossover trial."

Click here for more information on IVF acupuncture in Vancouver, and the IVF Acupuncture Group founder Dr. Spence Pentland