Fertility for Patients of East Asian Heritage
Acupuncture and Chinese Herbs
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Quick Summary
If you're looking for a more complete rundown of fertility treatment and acupuncture, we suggest you visit our dedicated course here. In the meantime, we believe the medical literature is frankly inconclusive on whether acupuncture helps women to deliver a healthy baby. Acupuncture is inherently hard to study and as a result we’ve seen a spectrum of conflicting results from trials. That said, it appears that acupuncture is:
Effective at mitigating patient anxiety during treatment
Useful compared to “no acupuncture” but no significant improvement versus a “placebo"
“Dose dependent” and more likely to be effective the more often it’s administered
More useful when started months before stimulation begins and continued through to embryo transfer
Why Acupuncture Is Hard to Study
Before we dive into whether acupuncture improves a woman's chances to have a baby, we should get familiar with the reasons acupuncture is hard to study according to western best practices. We’ll refer back to this when we consider what each study tells us or doesn’t tell us. Here are the issues in order of importance.
Confusion Around Control Arm (Most Important):
In assessing whether acupuncture “works” we need to compare it to an alternative. Compared to doing no acupuncture (“usual care”), acupuncture generally rates favorably. But compared to something patients perceive to be acupuncture (but is not), known as a “sham” or “placebo” acupuncture, acupuncture often looks ineffective. There is real debate as to which should be our comparator arm.
Inconsistent Timing & Volume of Treatment:
During an IVF cycle, treatment can be performed at many phases (e.g. leading up to a transfer, around the time of transfer, in the weeks after), and lining up the clinical data based on when treatment occurred is both important and hard. Most studies involve a total of two treatments performed on the day of embryo transfer, which is less treatment than many experts consider necessary.
Not "Real-World" Treatment:
Acupuncturists typically have a lot of leeway in where they place their needles. In the majority of these studies, the acupuncture treatment points were placed as per the specific protocol the investigators chose. Fixed protocols do not take into account the unique needs of an individual patient and thus, do not reflect the full impact of a tailored approach patients would receive outside of a study.
Old Data:
The available data is old and comes from an era when IVF success rates were lower. That matters because when acupuncture shows a benefit, it’s often in studies where IVF patients not given acupuncture had poor results. Today, many of those same patients might have fared better, making it harder for acupuncture to show additional benefit.
Inferior Endpoints:
We believe patients should be focused on whether doing acupuncture helps them have a live birth. Unfortunately, many acupuncture studies only look at whether acupuncture improves “pregnancy rates” (or some version thereof), which is useful but falls short of what we all truly care about: taking home a baby.
More Detail
While the impact of acupuncture has been widely studied (over 40 studies and 10 meta-analyses), we do not believe it’s been well studied (for the reasons mentioned above). With the data we currently have, this is how we’d summarize the findings:
Acupuncture clearly lowers patient anxiety and duress during fertility treatment
Greater volumes of treatment are more likely to improve outcomes rather than treatment just around embryo transfer
Acupuncture is more likely to show benefit versus “no acupuncture” but not versus a “sham” or “placebo” approach
Anxiety Reduction
Undergoing acupuncture during fertility treatment clearly mitigates stress. This is true regardless of whether acupuncture was administered just around the time of embryo transfer or during a longer duration of time. Below, we list the better run studies on the subject and most come to a similar conclusion. Meanwhile, we should point out that “anxiety reduction” may not be a byproduct for all patients. Some patients may find the process to be anxiety-producing if they’re burdened by finding treatment, working it into their calendars, stepping into a new environment, or cloistering in a room with a previously unknown person during COVID.
Anxiety and stress can be excruciating and addressing this alone may make acupuncture “effective”. Psychological anxiety also impedes a patient’s ability to get more fertility treatment.
This can limit a patient's likelihood of eventually deliverying, especially if she discontinues treatment at an early age or in the first few cycles.
Benefit of More Treatment
One single-center study measured the impact of doing acupuncture solely around the time of embryo transfer and compared that with results from patients who underwent 12 or more treatments (in additional to herbal therapy). Investigators noted significantly higher live birth rates associated with greater treatment. While this study has challenges (single center, not prospectively randomized), we think its endpoint (live birth), sample size (500+ patients), and level of statistical significance (P < .03) make it noteworthy. A broader meta-analysis showed patients who undergo as few as three treatments see a statistically significant impact in live birth rates.
Pregnancy & Live Birth Rates
The data generally shows acupuncture has a benefit compared with “usual care” but not when compared to “sham” or “placebo” (treatments that mimic acupuncture).
We think the best analysis comes from a 2013 meta-analysis by Manheimer and a 2019 meta-analysis by Smith, with each more-or-less coming to the below conclusion.
This raises a fundamental question about whether one should compare acupuncture against “usual care” or “sham / placebo.”
Acupuncture advocates prefer to compare it to “usual care” with the following rationale, which in our minds is credible:
By going to see a practitioner and relaxing in a quiet setting, patients who undergo “sham” treatment likely receive some benefit. As a result, this group is in fact receiving part of the therapy of acupuncture and so they are not truly a “placebo” or “sham” comparator.
In the real world, patients only choose between getting acupuncture or not getting it. Designing a trial to compare acupuncture against a non-practical option (e.g. receiving “sham” acupuncture) produces irrelevant information.
Of the 40-plus studies done on the subject, we believe the ones below are the most credible.
PCOS & Acupuncture
Trying to Conceive, No IVF:
Women with PCOS often suffer from ovulation infrequency and one small, but credible, study showed that women who underwent 10-13 weeks of acupuncture saw ovulation improvement versus a control group.
However, the study stopped short of looking at women actually trying to conceive. Two studies went a step further and neither showed acupuncture had an impact.
Trying To Conceive, Using IVF:
We have two studies to work with here, and both are imperfect. The best run trial by Rashidi showed that acupuncture patients had a higher ongoing pregnancy rate, but the difference was not large enough to meet statistical significance, likely due to the study’s small size.
A meta-analysis by Jo pools multiple studies on the subject (including Rashidi’s), and while this beefs up the sample size we have to work with, the variability in the groups studied creates chaos in the data. Jo’s study showed no difference in live birth rate between the acupuncture and non-acupuncture groups.
A 2022 systematic review and meta analysis conducted by Masoud and colleagues found that when acupuncture is used as an adjunct therapy to IVF, it led to lowered clinical and ongoing pregnancy rates compared with placebo within China, but increased both outcomes in studies conducted outside of China, concluding that there is “no clear evidence at this time to support the role of acupuncture” as an adjunct to IVF.
Male Factor Infertility & Acupuncture
There is little published literature on the effects of acupuncture on men and its ability to improve their chances of fathering a child. Unfortunately, the best data we have addresses whether acupuncture improves a man’s semen parameters which does not necessarily translate into a higher live birth rate.
What’s more, for men suffering from non-obstructive azoospermia (those who produce no sperm), we believe acupuncture is unlikely to make any difference.
In one small, but relatively well-run study (12 treatments, prospective study with good randomization) in patients with extremely low sperm concentrations (<1 million per mL), acupuncture showed a statistically significant decrease in sperm concentration while having a slight improvement on the percentage of sperm that are able to swim (motility). In populations with such low sperm volumes, neither change is likely to impact the chances of a couple’s ability to conceive.
When Chinese investigators performed a meta-analysis on the studies addressing this topic more broadly (and not just in those men who have severely low concentrations) they concluded the evidence was “insufficient” on whether acupuncture improves semen parameters.
Endometriosis and Acupuncture
While the data is scant on whether acupuncture helps women with endometriosis conceive, there is reason to believe that endometriosis patients benefit from acupuncture in the form of pain relief. One small, randomized control trial out of China noted that women with endometriosis experienced lower pain rates related to Dysmenorrhoea on a 15 point scale by a wide, 5 point margin.
Chinese Herbs
Efficacy of Herbs
Many acupuncturists will prescribe and dispense herbs to address a patient’s fertility issues. There is a wide variety and combination of herbs that can be used, and we may overgeneralize at times in this section.
Unfortunately, the quality of our data around the efficacy of herbs in conjunction with IVF is poor, even worse than our data around acupuncture and IVF. Today, we have roughly 20 studies on the subject, but nearly all are small and suffer from major design flaws. Presuming this is the best data we have to work with, the meta-analysis below suggests that use of herbs improves pregnancy rates. However, the authors urge “extreme caution” about reading too heavily into the results. We would not be surprised if this data proved wrong when more rigorously studied.
Safety of Herbs
We should point out that most fertility doctors prohibit their patients from using herbs leading up to an egg retrieval or ahead of a programmed embryo transfer where estrogen or progesterone is used. The fear is that using herbs in conjunction with these medications, or around the time of anesthesia, could result in a bleeding issue or have an impact on the drug’s ability to work. We’ve yet to see the data that supports this fear.
When Cao looked through the safety record of the above mentioned 20 trials, she noted patients taking herbs before or during IVF suffered no higher rates of miscarriage or OHSS than those who did not take herbs.
Finally, patients must be extremely careful taking herbs from an unvetted source. Many experts feel there is little-to-no regulation to ensure herbs given to patients have been properly grown or processed. We suggest relying upon your acupuncturist and doctor for guidance and letting them know about any herbal medications you may be taking.
Popular Herbs
There is a spectrum of herbs acupuncturists can prescribe and the reality is we see a lot of trial and error in the process. All the same, below are four herbs that are frequently used. While many have a plausible case to be helpful, almost none have hard data that demonstrates they improve live birth rates in humans. We believe this is a result of omission (nobody has studied this thoroughly) rather than commission (the studies were done and turned out negative).
Vitex (Chaste Tree Berry)
Vitex is a popular herb for balancing the menstrual cycle and resolving PMS. It likely acts on the pituitary gland in the brain, increasing the strength of the Luteinizing Hormone (LH) surge, which triggers ovulation. This in turn can strengthen ovulation and progesterone production in the luteal phase (when your ovaries have released the eggs and the endomtrium prepares to receive an embryo). It has also been shown to decrease abnormally high prolactin, thus improving hormone balance and ovarian function. This herb helps women with ovulation problems and women with luteal phase defect who have a short luteal phase or low progesterone production.
Maca (Lepidium Meyenii)
Maca has been used as a libido and fertility enhancing medicinal. It is indigenous to the Peruvian Andes and is a tuber (like a turnip). It acts as an adaptogen, helping the body cope during times of increased stress, but it may also affect androgens (testosterone) in both men and women. It is unclear if it affects actual levels of testosterone or just the receptor, but it has been shown in one very small study in males to improve semen parameters. Unfortunately, our only confirmatory data in females is limited to mice. In light of the effects on testosterone activity, however, this supplement may not be helpful for women with PCOS, which often is associated with elevated male sex hormones, like testosterone.
Cinnamon
Cinnamon may improve fertility in both men and women. In Chinese medicine, cinnamon bark (the spice) is used to warm the interior and nourish yang energy, which must be abundant for fertility. Our best data on the effect of cinnamon in males is encouraging (improvement in semen parameters) but is too early (in mice) to offer reassurance. Studies have also demonstrated that cinnamon affects blood sugar balance and the insulin response, so it may be helpful for metabolic syndrome and women with PCOS as well.
Tribulus terrestris
Tribulus may be helpful for both male and female fertility. In women with irregular ovulation, especially due to PCOS, tribulus may help normalize the cycle and create predictable ovulation. One study showed it also increased conception rates (when both partners took it) in couples that had high levels of anti-sperm antibodies. That same study saw an improvement in the male’s sperm parameters, including motility, concentration, and volume.
Pro Tips
While the data on herbal impact on success rates is encouraging, interpret it with caution.
Let your reproductive endocrinologist know if you are taking herbs. They may have concerns about its interaction with injectable hormones.
Let your acupuncturist know when and if you have begun injectible hormones.
Only take herbs provided to you by a trusted or vetted source. There is no regulatory oversight to ensure herbs have been safely processed.
Ensure your acupuncturist has the proper credentialing to prescribe herbs.