28 Acupuncture and In Vitro Fertilisation: Recent Research and Clinical Guidelines Journal of Chinese Medicine • Number 84 • June 2007

Acupuncture and In Vitro

Fertilisation: Recent Research
and Clinical Guidelines
By: Lara Abstract
Rosenthal The use of acupuncture to improve the outcome of in vitro fertilisation (IVF) has become widespread over the past
and Belinda five years. Three of four randomised controlled trials (RCT) published since 2002 have shown that acupuncture
Anderson significantly increases pregnancy rates. Although the research has a number of methodological limitations, it does
strongly endorse the use of acupuncture during IVF. Protocols for IVF are complex, involving multiple phases with
Keywords: specific physiological aims. Correspondingly, acupuncture treatments before and during IVF need to be carefully
Acupuncture, considered in relation to the biomedical aspects that are being manipulated. This article summarises recent research
in vitro in this area, and provides an explanation of the IVF process and associated acupuncture treatment guidelines.
fertilisation
(IVF), infertility, Introduction

R
Chinese ecent estimates suggest that 10-15% of The causes of female infertility can be broadly
medicine, couples in the US experience infertility, with grouped into four major categories (Strauss et al,
assisted the prevalence higher in women over age 34 2002): 1. Abnormalities in oocyte production; 2.
reproductive (Wright et al, 2001). In vitro fertilisation (IVF) is the Anatomic abnormalities leading to obstruction of
technology most successful of the infertility treatments, and for transport of the sperm, oocyte, and/or embryo
(ART) many people is the last possibility for pregnancy. In through the reproductive tract (i.e., tubal, uterine,
2001 (the most recent year for which national data cervical and peritoneal factors); 3. Abnormalities in
were published) there were 29,344 deliveries from the implantation process, including early defects
IVF, which resulted in the birth of 40,687 infants. This in embryo development, and embryo-endometrial
represents 1% of all U.S. births in that year (Wright et interaction; and 4. Numerous other factors that are
al, 2001). probably most important in women with unexplained
Three to six cycles of standard IVF can now result infertility (e.g. age, body weight, cigarette smoking,
in over 65% of patients ultimately delivering a baby alcohol and caffeine intake, psychological and
(Kovacs et al, 2001; Olivius et al, 2002). However emotional factors, immunological abnormalities and
the average delivery rate of IVF per single initiated borderline hormonal imbalances).
cycle using fresh, non-donor oocytes was still only The IVF procedure can overcome many of the
33% (2001 Assisted Reproductive Technology Success conditions that cause infertility by artificially
Rates; CDC Reproductive Health; 2003). Therefore, modifying oocyte production, fertilising oocytes in-
the majority of IVF cycles do not result in pregnancy, vitro, and ensuring delivery of one or more embryos
and there is generally the need for multiple IVF cycles into a hormonally stimulated endometrium. For these
for pregnancy to be achieved. reasons, combined with the superior success of IVF
Due to the relatively low success rate of IVF per compared to other assisted reproductive technologies,
cycle, as well as the high emotional and financial IVF is now widely used for the treatment of infertility
costs associated with IVF, many patients have turned of known and unexplained aetiology.
to complementary and alternative medical (CAM)
treatments to enhance the success of IVF treatment The IVF process
(Beal et al, 1998). Among CAM treatments acupuncture The IVF process has several phases that must all be
is a frequently used adjunctive therapy. very carefully coordinated and precisely timed. There
are several different protocols, the details of which are
Infertility from a biomedical perspective beyond the scope of this paper, and these protocols
A growing body of research has begun to identify are constantly being refined, creating some variability
a number of physiological and psychological in procedures among different women, IVF centres
mechanisms that may underlie female infertility and and physicians. A diagram of the basic timeline is
explain the limited success of IVF treatments. shown in Figure 1.
Journal of Chinese Medicine • Number 84 • June 2007 Acupuncture and In Vitro Fertilisation: Recent Research and Clinical Guidelines 29

10days-2months 10-14d 33-35hr 3-5d 14 days after oocyte retrieval

|----------------------------------------|---------------------------------|-------|----------------|------------------------------------------|
timing & hormonal ovulation hCG oocyte embryo 1st pregnancy
down-regulation induction trigger retrieval transfer test (hCG)

Timing and hormonal down-regulation Laboratory component Figure 1:

Most commonly, the IVF protocol begins with In the laboratory, oocytes are identified under a Timeline
regulation of hormones. Many clinics use the oral microscope, graded for maturity, and placed in an for IVF
contraceptive pill (OCP) followed by GnRH agonist incubation medium in a petri dish by an embryologist.
Lupron to suppress the natural cycle and inhibit Oocytes are generally cultured for three to six hours
ovulation, thereby allowing the ovaries to “rest” prior before being exposed to sperm.
to stimulation. The OCP can be used for ten days to The sperm may have already undergone several
two months, in some cases to coordinate timing for a procedures to help improve the quality of the sample
batch of women. Lupron is generally given for five to to be utilised. In cases of poor sperm quality or low
ten days. numbers, the sperm may be injected directly into the
oocyte in a procedure called intracytoplasmic sperm
Ovulation induction injection or ICSI.
In ovulation induction, the ovaries are stimulated to The sperm and oocytes are incubated overnight
produce multiple follicles. Gonadotropin drugs such in an incubation medium with nutrients that allow
as Follistim, Gonal-F or Bravelle are begun day 2-3 fertilisation to occur. The next morning, the oocytes
of the menstrual cycle. Dosages can vary significantly are checked for signs of fertilisation and then on the
depending on age and perceived ovarian function. following days for development. Not all the eggs will
Generally the younger the woman and the healthier fertilise and not all of the fertilised eggs will continue
the ovaries, the lower the dosage. The older the to divide. The embryos will be allowed to grow to the
woman, or if there are other factors such as previous five to six-cell to eight-cell stage (day three) or to the
poor response to ovarian stimulation, the higher the blastocyst stage (day five) before being returned to
dosage. In addition, Lupron or the GnRH antagonist the woman’s uterus.
Antagon, are used to prevent premature ovulation.
During the stimulation phase, the woman’s Embryo transfer
oestrogen and LH levels are carefully monitored Prior to embryo transfer (ET), the embryos are
using blood tests, and follicular development is graded in terms of appearance and development.
tracked by ultrasound, in many cases daily, so that The best embryos are selected and gently placed into
the gonadotropin dosage can be adjusted accordingly. the uterus via a catheter inserted through the cervix.
Often clinics aim to produce between 10-20 follicles, Embryo transfer is an outpatient procedure, which
however in older women, five to six follicles may be takes only a few minutes to perform and no pain
considered a good response. relief is required. Most programs transfer two to three
embryos in patients under age 35 and three+ embryos
HCG trigger in women over 35 to maximise the chance of success.
Just before ovulation would be occurring the patient If there are additional embryos, they can be frozen for
is given an injection of hCG (human chorionic use later if implantation and pregnancy do not occur.
gonadotropin) to help complete the final stages of
maturation. The hCG trigger is given 33-35 hours Luteal phase monitoring
before oocyte retrieval. In order to help support the endometrium and
increase the chance of success, progesterone is given
Oocyte retrieval in either vaginal suppositories, injections with oil,
Oocyte retrieval is a surgical procedure performed or micronised oral tablets. A pregnancy (hCG) test is
under either local or general anaesthesia, in which given 14 days after oocyte retrieval.
the follicular fluid containing the eggs is collected. A
long thin needle is inserted through the vagina and Side effects of IVF
into the ovaries. The follicular fluid is aspirated into The process of IVF can be quite gruelling for the
the lumen of the needle and withdrawn. The fluid is patient. It involves receiving numerous injections
then transferred to a special laboratory. of drugs, with subsequent soreness and bruising, as
well as getting up early to get to the IVF centre for
30 Acupuncture and In Vitro Fertilisation: Recent Research and Clinical Guidelines Journal of Chinese Medicine • Number 84 • June 2007

Relevant
Study Study Interventions/
Author/Year Acupuncture treatment Outcomes Results
design population sample size
measured
• MA
• Women receiving Acu
• 25 min before and after ET • Clinical pregnancy
had a higher clinical
- presence of a
• 160 women pregnancy rate (42.5%
• Acu (n=80) Before: Neiguan P-6, Diji SP-8, Taichong foetal sac (by
1. Paulus et al, • Age 32.5 y; vs 26.3%)
RCT • Control: No Acu LlV-3, Baihui DU-20, Guilai ST-29 ultrasound) 6 wk
2002 range 28.5- • No difference between
(n=80) After: Zusanli ST-36, Sanyinjiao SP-6, post ET
36.5 y the acu and no acu
Xuehai SP-10, Hegu L.I.-4 • Uterine artery
groups in the uterine
Ear: Shenmen, Zigong (Uterus), Naodian pulsatility index
artery pulsatility index
(Brain), Neifenmi (Endocrine)

• MA
• Acu group compared
• Two txs 30 mins & 3 days after ET
to the placebo group
had sign higher clinical
30 min after ET: Guanyuan REN-4, Qihai • Clinical preg rate
preg rate (33.6% vs
• 225 Women • Acu (n=116) REN-6, Guilai ST-29, Neiguan P-6, Diji • Biochemical preg
15.6%), biochemical
2. Dieterle et • Avg age 34.9 • Control: placebo SP-8, Xuehai SP-10 (+ear seeds) rate
RCT preg rate (35.3% vs
al, 2006 y; range 31.3- Acu (sham pts) 3 days after ET: Hegu L.I.-4, Sanyinjiao • Implantations rate
16.5%), implantation
38.9 y (n=109) SP-6, Zusanli ST-36, Taixi KID-3, • Ongoing preg rate
rate (14.2% vs 5.9%),
Taichong LIV-3 (+ear seeds) • Miscarriages
& ongoing preg rate
Sham Pts: Sidu SJ-9, Xiaoluo SJ-12,
(28.4% vs 13.8%)
Fengshi GB-31, Zhongdu GB-32,
• No diff in miscarriages
Yanglingquan GB-34 (+sham ear seeds)

• MA
• 3 txs: Day 9 of stimulating injections,
• Acu (n=110) before & after ET • Clinical preg rate • No sign diffs in any
• 128 Women
• Control: Placebo • Implantation outcomes
3. Smith et al, • Avg age 36 y;
RCT (sham pts, Ist Tx based on TCM Dx (6-14 needles) • Ongoing preg • Clinical preg rate: Acu
2006 range 31.2-
Streitberger) Txs before and after ET were the same • Adverse events vs placebo – 34% vs
40.9 y
(n=118) as Paulus, without Zhongfeng-LIV-4 • Health status 27%
(?Taichong LIV-3) and Baihui DU-20
Sham tx used pts close to the real pts

• Acu-1 group
• MA compared to control
• 25 min before & after ET (Acu-1); plus had sign higher clinical
2 days post ET (Acu-2) and ongoing preg rates
(39% vs 26% & 36% vs
• Acu-1 tx (n=95)
• 273 Women Before ET: Baihui DU-20, Guilai ST-29, 22%)
4. Westergaard • Acu -2 tx (n=91) • Clinical preg
RCT • Avg age 37 y; Diji SP-8, Neiguan P-6, Taichong LIV-3 • Acu-2 group not sign
et al, 2006 • Control: no acu • Ongoing preg
range 24-45 y Acu 1: Zusanli ST-36, Sanyinjiao SP-6, diff to control
(n=87)
Xuehai SP-10, Hegu L.I.-4 • Acu-2 had a higher,
Acu 2: Baihui DU-20, Zhongji REN-3, but not sign, early preg
Guilai ST-29, Xuehai SP-10, Sanyinjiao loss compared to Acu-
SP-6, Zusanli ST-36, Hegu L.I.-4 1 & control (33% vs
15% vs 21%)

Abbreviations: Acu – acupuncture; Avg – average; ET – embryo transfer; MA – manual acupuncture; preg – pregnancy; RCT – randomised
controlled trial; sign – significant to at least p < 0.05; y – year; Tx – treatment

Table 1: blood and ultrasound monitoring, in addition to the During the luteal phase, many women experience
Summary of emotional and financial pressure for it to be successful bloating, dizziness, depression, breast tenderness,
RCTs Evaluating (Verhaak et al, 2007). All this is difficult to separate out headache, abdominal pain and distention, nausea and
Acupuncture from the effects of the drugs themselves. What is clear irritability. And throughout the cycle injectible drugs
as an Adjunct is that undergoing IVF is a highly stressful experience are used so injection site reactions such as tenderness,
Therapy for IVF for most women. While some feel fine during parts of infection, haematoma and swelling or bruising at the
it, others feel irritable and bloated throughout. injection site are commonplace.
During down-regulation, the most common side The most serious risk of IVF is ovarian
effects include hot flushes, night sweats, emotional hyperstimulation syndrome (OHSS), which is classified
lability, insomnia, depression, headaches, decreased as mild, moderate or severe. IVF hyperstimulates
libido, bloating and fatigue. In ovulation induction, the ovaries on purpose in order to produce multiple
patients often experience depression, irritability, follicles, thus very mild OHSS symptoms such as
headache, abdominal or pelvic pain or pressure, bloating and lower abdominal tenderness occur
bloating, weight gain and fatigue. Following oocyte routinely in many women undergoing IVF. However,
retrieval some women experience abdominal pain. a small percentage of women will produce too many
Journal of Chinese Medicine • Number 84 • June 2007 Acupuncture and In Vitro Fertilisation: Recent Research and Clinical Guidelines 31

follicles, sending oestrogen to potentially dangerous Subjects in the real acupuncture group as compared with
levels, and causing the ovaries to become swollen and the sham group exhibited statistically non-significant
enlarged. Symptoms of severe OHSS include severe trends towards higher pregnancy rates (31% vs 23%) and
pelvic pain, swelling of the hands or legs, abdominal pain ongoing pregnancy rates at 18 weeks (28% vs 18%).
and swelling, shortness of breath, weight gain, low urine Westergaard et al (2006), in a study of women (average
output, diarrhoea, and nausea or vomiting. Severe OHSS age 37 years) undergoing IVF with and without ICSI,
can be fatal so it is crucial to get prompt medical attention compared subjects that had not received acupuncture (n
if an IVF patient starts experiencing these symptoms. = 87) with those that received acupuncture immediately
before and after ET (ACU 1 group, n = 95), and with an
Research into the use of acupuncture to improve IVF additional acupuncture treatment two days post ET (ACU
outcomes 2 group, n = 91). Clinical and ongoing pregnancy rates
There have been several studies investigating the use of were significantly higher in the ACU 1 group as compared
acupuncture to improve the outcome of IVF (Anderson et with controls (39% vs 26% and 36% vs 22%, respectively).
al, 2007). The highest quality and most conclusive studies The ACU 2 group as compared with the control group
are the four randomised controlled trials (RCT) that exhibited statistically non-significant trends towards
specifically addressed the hypothesis that acupuncture can higher clinical and ongoing pregnancy rates (36% and
improve the outcome of IVF (Paulus et al, 2002; Dieterle et 26%).
al, 2006; Smith et al, 2006; Westergaard et al, 2006). These
studies are summarised in Table 1. Of these four RCTs two Significance and limitations of the RCTs
had sham acupuncture controls (Dieterle et al, 2006; Smith These RCTs suggest that acupuncture may improve the
et al, 2006). Three of the RCTs present evidence suggesting outcome of IVF, and that it is a safe adjunctive therapy for
acupuncture can significantly improve the success of IVF. women undergoing IVF as no adverse events associated
The first study by Paulus and colleagues (2002) included with the acupuncture intervention were reported.
160 women (average age 32.5 years) undergoing IVF with However these results must be considered inconclusive
or without intracytoplasmic sperm injection (ICSI). Two and interpreted with caution for several reasons (Collins,
groups were compared (n = 80 each). One group received 2006; Domar, 2006; Meyers 2006; Anderson and Rosenthal,
acupuncture 25 minutes before and 25 minutes after 2007). Firstly the majority of available studies have
ET, and the other underwent a standard IVF procedure significant design limitations. Only two of the four RCTs
without acupuncture. The clinical pregnancy rate in the included sham acupuncture controls. In studies without
non-acupuncture group was 21/80 (26.3%) compared to a sham control it is difficult to distinguish the effects of
34/80 (42.5%) in the acupuncture group. acupuncture needling from placebogenic, non-specific
The Paulus et al (2002) study provided the impetus effects associated with treatments (Kaptchuk, 2002; Birch
for further studies, three of which were published in 2003). In many studies details of procedures related
2006 (Dieterle et al, 2006; Smith et al, 2006; Westergaard to eligibility screening, randomisation, blinding and
et al, 2006). Dieterle et al (2006), in a study involving 225 statistical analyses were often absent, as noted previously
women (average age 34.9 years), investigated the effect (Collins, 2006; Domar, 2006; Meyers 2006).
of real (n = 116) and sham (n = 109) acupuncture on the Secondly the majority of the acupuncture protocols
outcome of IVF with and without ICSI. Sham acupuncture employed in studies to date do not reflect clinical practice.
was performed by using points that were not appropriate The dosages of acupuncture employed in most of the trials
for fertility-related conditions. Two manual acupuncture were very low (two to three treatments). TCM diagnoses
treatments were given 30 minutes and three days after ET. were only assessed in one of the RCTs (Smith et al, 2006),
The group that received real acupuncture compared with and even in this study were not used to determine all
the sham group had significantly higher implantation acupuncture treatments. In the other three RCTs treatment
rates (14.2% vs 5.9%), clinical pregnancy rates (33.6% vs protocols were not tailored to address specific TCM
15.6%), biochemical pregnancy rates (35.3% vs 16.5%), and diagnoses and the same treatment protocol was given
ongoing pregnancy rates (28.4% vs 13.8%). to all subjects. This potentially creates a fixed protocol
Smith et al (2006) compared real acupuncture to sham bias and reduces the likelihood that the treatment will be
acupuncture. The sham intervention involved the use of appropriate and effective for individual subjects (Schnyer
non-acupuncture points and the non-insertive Streitberger et al, 2006).
needle (the shaft of the needle collapses into the needle The choice of acupuncture points was often difficult
handle), in women undergoing IVF with and without ICSI. to understand and justify and without a high degree of
All subjects (average age 36 years, randomised into two n similarity to suggested protocols in Chinese medicine
= 114 groups) received three acupuncture treatments on texts (Maciocia, 1998; Liang, 2003; Lyttleton, 2004).
day nine of stimulating injections, and immediately before Furthermore some points (Sanyinjiao SP-6 and Hegu
and after ET (similar to Paulus et al mentioned above). L.I.-4) are contraindicated in pregnancy and may therefore
32 Acupuncture and In Vitro Fertilisation: Recent Research and Clinical Guidelines Journal of Chinese Medicine • Number 84 • June 2007

be unsuitable after ET. This may explain the outcome underpinnings of the reproductive system. Kidney yin,
reported by Westergaard et al (2006) of a greater early with its substantive and cooling properties, correlates
pregnancy loss in the group who were given acupuncture to oestrogen and FSH. Kidney yang, with its warming
two days after ET, as compared with those not receiving and holding properties, correlates to progesterone and
acupuncture, and those only receiving acupuncture testosterone.
immediately before and after ET (33% vs 21% vs 15%
respectively). Heart
Thirdly, important details of the experimental protocol The Heart governs the emotions, thus explaining the
were not provided. The qualifications and experience of the impact of stress and emotions on fertility. Lyttleton (2004)
acupuncturists involved in the design and administration says, “the Heart encompasses the mind and the activity of
of the treatment protocols are poorly described, making the hypothalamus and pituitary, which controls the whole
it difficult to assess the validity of the intervention. cycle … old Chinese medicine texts describe the Heart
Additionally many other details of the experimental as the master controller (Emperor) of the other organs.
protocol, as suggested by STRICTA (MacPherson et In the same way, Western medicine often refers to the
al, 2001), were not reported making the quality of the hypothalamus and pituitary as the master controllers of
outcomes from these trials difficult to evaluate. the other glands in the body.”
In summary, although methodological problems with
the existing clinical research limit conclusions, there is Uterus
some evidence to suggest that acupuncture may be a safe The Uterus, or Bao Gong, includes not only the anatomical
and effective adjunct therapy for women undergoing IVF. uterus, but also, according to Lyttleton (2004), all the
There is a definite need for more thorough and carefully reproductive organs in the pelvis including the ovaries
designed clinical trials to evaluate the effect of acupuncture and fallopian tubes. In TCM, the Uterus is connected
on IVF success rate. energetically to the Heart via the Bao Mai or Uterus Vessel,
and to the Kidney via the Bao Luo or Uterus Channel. In
Infertility from a Chinese medicine perspective TCM it is said that the menstrual blood comes down to
Chinese medical treatment of infertility began long before the Uterus from the Heart, though there is no physical
the advent of modern technologies like IVF. There were structure that can be shown to do this.
no blood tests to measure oestrogen or progesterone levels
or ultrasounds to determine the development of follicles Liver and Spleen
or presence of cysts. Instead, diagnosis and treatment In addition to the above organs, the health of the Liver and
were based upon detailed observation of external signs Spleen also performs a central role in reproduction. The
and symptoms. In modern practice, integrating medical Liver regulates the smooth flow of qi, as well as moving
disease diagnoses, blood tests and stages of the IVF process and storing blood. The Spleen is of paramount importance
can help further refine TCM diagnosis and treatment, and in the generation of blood and qi.
improve clinical outcomes.
Traditional Chinese medicine texts (Maciocia, 1998; Other organs
Liang, 2003; Lyttleton, 2004) say the Uterus, Heart, and Though rarely spoken about in TCM texts, other organs
Kidney form the core of reproductive activity. such as the Large Intestine and Lung may also play an
indirect role. If constipation is a significant issue the entire
Kidney pelvic region is in a greater state of stagnation. This slow
The Kidney houses reproductive essence (jing) and transit time can influence steroid hormone levels (Stephen
governs reproduction. In modern terminology, essence et al, 1999). In cases of extreme asthma or other Lung
refers to eggs and sperm, the most primordial building pathologies, the Lung’s contribution to the production of
blocks of reproduction. As we age, our inherited essence qi can be inhibited to the point where it becomes a fertility
decreases. We can see this clearly in a woman’s maturation. issue. While these are not main causes of infertility, when
As a twenty week old foetus, a woman has 6-7 million they become more extreme they should not be ignored.
eggs, the greatest number she will have in her lifetime. By
birth, that number falls to 1-2 million eggs. By puberty, a Acupuncture through the stages of IVF
scant 300,000-400,000 remains. Of these, perhaps 300-400 Thus far, research has only investigated the use of
will be ovulated during a woman’s reproductive lifetime. acupuncture in the very narrow window before and after
This perhaps reflects the use of precious essence in the IVF embryo transfer. There have been no clinical studies
incredibly energy expensive process of growing from a investigating the use of acupuncture in preparation for
few cells into a foetus and from a baby into an adult. IVF or a detailed investigation of acupuncture during the
While Kidney essence correlates to eggs and sperm, stages of IVF as outlined by Liang (2003). Thus, in clinical
Kidney yin and yang can be thought of as the hormonal practice, one may choose to stick to the well-documented
Journal of Chinese Medicine • Number 84 • June 2007 Acupuncture and In Vitro Fertilisation: Recent Research and Clinical Guidelines 33

Acupuncture treatments

Phase 1 2 3 4 5
|-------------------------|-----------------------|---------------------------------------|-------------------|------------------------------------------------------|
Tx Prep for IVF Tx during Tx during ovulation induction Tx before/ after Tx to maintain pregnancy
TCM Pattern Dx down-regulation embryo transfer

Acupuncture treatment phases (Liang, 2003)

Phase 1: Tx (treatment) is according to the TCM Dx (differentiation)
Phase 2: Zusanli ST-36, Sanyinjiao SP-6, Taichong LIV-3, Hegu L.I.-4, Yintang (Modification: Xuehai SP-10, Zigongxue M-CA-18)
Phase 3: Zusanli ST-36, Sanyinjiao SP-6, Taichong LIV-3, Hegu L.I.-4, Taixi KID-3, Yintang, Baihui DU-20, Zigongxue M-CA-18
Phase 4: Before ET: Zusanli ST-36, Sanyinjiao SP-6, Taichong LIV-3, Hegu L.I.-4, Taixi KID-3, Yintang, Qixue KID-13, Baihui DU-20, Sishencong M-HN-1; Ear – Shenmen, Kidney, Liver,
Spleen; After ET: Zusanli ST-36, Taixi KID-3, Yintang M-HN-3, Baihui DU-20, and Ear – Kidney, Shenmen, point halfway between Liver and Spleen
Phase 5: Up to 1st hCG: use after ET protocol
After positive hCG: Yintang, Baihui DU-20, and Ear – Kidney, Shen Men, point halfway between Liver and Spleen
In case of threatened miscarriage: Baihui DU-20, Sishencong M-CA-18, Yintang M-HN-3, Ear – Shenmen, Kidney, point halfway between Liver and Spleen

Paulus (2002) protocol and perform acupuncture only BBT data is being collected, acupuncture can be Figure 2:
before and after embryo transfer. Or one may prepare administered once or twice per week, using points Timeline for
the body for IVF by beginning acupuncture three determined by the patient’s TCM pattern diagnosis. acupuncture
months ahead of IVF and continuing throughout treatments
the stages of IVF. A diagram of the stages of IVF and 2. Timing and down regulation during IVF
proposed acupuncture treatments is shown in Figure Once the patient begins hormonal down-regulation,
2. This adapted from Liang (2003). the acupuncture protocol and treatment strategy
is tailored to be compatible with the goals of the
1. Preparation of IVF / TCM pattern diagnosis IVF medications. During down-regulation, the goal
The TCM patterns can be informed by the patient’s is to allow the ovaries to rest. Lupron can cause
Western medical diagnosis as well as by the standard pronounced yin deficiency or deficiency heat signs, as
diagnostic tools of Chinese medicine. According to well as qi stagnation. Thus, one can use acupuncture
Liang (2003) the various Western medical infertility points to gently nourish yin, clear heat, and move qi.
diagnoses can be viewed within the context of the Liang recommends Zusanli ST-36, Sanyinjiao SP-6,
various TCM patterns. TCM pattern diagnoses of Taichong LIV-3, Hegu L.I.-4, Yintang (M-HN-3) with
Kidney yin deficiency, Kidney yang deficiency, Diji SP-10 and Zigongxue M-CA-18 if needed to move
blood deficiency and qi deficiency include the blood.
western medical diagnoses of anovulation, small or
misshapen uterus, poor follicle and/or egg quality, 3. Ovulation induction
low oestradiol, low progesterone and high FSH. During ovulation induction, just as the gonadotropins
TCM pattern diagnoses of qi stagnation, blood stasis stimulate the production of multiple follicles, so can
and phlegm-damp obstruction include the western acupuncture support the movement of blood in the
medical diagnoses of blocked fallopian tubes, uterine pelvis, as well as tonifying Kidney yin and blood
fibroids, ovarian cysts, endometriosis, adhesions to improve the body’s response to the medications
and stress. The TCM pattern diagnosis of damp- and to improve circulation of blood in the pelvis.
heat includes the Western medical diagnoses of During this phase Liang recommends Zusanli
infections of the cervix, vagina, pelvis, urinary tract ST-36, Sanyinjiao SP-6, Taichong LIV-3, Hegu L.I.-4,
and fallopian tubes. Unexplained infertility, the most Taixi KID-3, Yintang (M-HN-3), Baihui DU-20 and
common medical diagnosis, generally presents as Zigongxue M-CA-18. Some practitioners also utilise
a combination of TCM patterns. Table 2 details the points such as Lieque LU-7, Zhaohai KID-6, Gongsun
most common TCM diagnostic patterns, along with SP-4, Neiguan P-6, to open the Conception (Ren) and
signs and symptoms and acupuncture points to treat Penetrating (Chong) vessels, plus additional points
female infertility. based on the patient’s pattern diagnosis. Commonly,
A further level of refinement in the development of three to four acupuncture treatments are given prior
a more nuanced TCM pattern diagnosis and treatment to oocyte retrieval.
strategy can be achieved by interpreting a basal body
temperature chart (BBT) through a TCM lens. The 4. Before and after embryo transfer
interpretation of BBT charts is a powerful tool. Though As discussed earlier, research studies looked at
it is beyond the scope of this article, we encourage acupuncture delivered 25-30 minutes before and
readers to study it further in Lyttleton (2004). Whilst after ET. When possible, that is certainly supported
34 Acupuncture and In Vitro Fertilisation: Recent Research and Clinical Guidelines Journal of Chinese Medicine • Number 84 • June 2007

TCM Diagnosis Diagnostic Signs and Symptoms Acupuncture Points

Developmental disorders of the reproductive organs, poor development of

Kidney jing secondary sexual signs like breast development, under-functioning ovaries Guanyuan REN-4, Shenshu BL-23,
deficiency (poor response to fertility drugs) Mingmen DU-4
Pulse-weak (esp. 3rd position); Tongue-pale
Malar flush, night sweats, thirst, symptoms worse in afternoon and evening,
Sanyinjiao SP- 6, Taixi KID-3,
Kidney yin insomnia, restlessness, irritability, weak/sore lower back and knees, hot
Fuliu KID-7, Shenmen HE-7, Rangu
deficiency flashes; Period-scanty or heavy bright red
KID-2, Zhaohai KID-6, Lieque LU-7
Pulse-rapid, fine; Tongue-red, peeled
Cold sensations, weak/sore lower back and knees, frequent urination,
nocturia, copious and clear urine, swollen ankles, puffiness or overweight,
Kidney yang Shenshu BL-23, Mingmen DU-4,
fatigue, low libido; Period-diarrhoea and low back pain just before or at
deficiency Fuliu KID-7
beginning, dysmenorrhoea, clots composed of tissue
Pulse-slow, deep; Tongue-swollen, pale, wet
Dry eyes, dry skin, pale complexion, brittle nails, dizziness, poor memory,
Zusanli ST-36, Sanyinjiao SP-6,
fatigue, numbness; Period-amenorrhoea, irregular periods, long cycle length,
Blood deficiency Ququan LIV-8, Xuehai SP-10,
scanty period
Geshu BL-17, Danshu BL-19
Pulse-weak, fine, empty; Tongue-pale

Fatigue, poor appetite, spontaneous sweating, low voice, poor digestion;

Qihai REN-6, Zusanli ST-36,
Qi deficiency Period-scanty or heavy, early or late
Sanyinjiao SP-6, Taiyuan LU-9
Pulse-weak; Tongue-swollen, pale

Palpitations, anxiety, insomnia, hysteria/neurosis, emotional stress; Period-

Heart qi Neiguan P-6, Shenmen HE-7,
irregular, or amenorrhoea which was preceded by emotional shock
stagnation Ear Shenmen, Taichong LIV-3
Pulse-knotted (esp. left 1st position); Tongue-red tip

Sub-costal pain, intermittent moving pain, irritability, anger, depression,

sighing, PMS, breast distention, stress, headaches with blood shot eyes, Hegu L.I.-4, Taichong LIV-3,
Liver qi stagnation
endometriosis; Period-late, irregular Qimen LIV-14, Xingjian LIV-2
Pulse-wiry; Tongue-normal

Table 2: TCM by the research. However, in clinical practice this is DU-20, and Ear: Kidney, Shenmen and a point halfway
diagnostic not always possible. Many clinicians feel that treating between Liver and Spleen. She notes that Zusanli ST-36
patterns by acupuncture 12-24 hours before and after ET is and Taixi KID-3 should be used only immediately
of female also useful, though this has not been studied. The after transfer and omitted after a positive pregnancy
infertility, Paulus (2002) protocol that was used as the basis for test because of their strongly stimulating properties.
associated the studies is as follows: before ET: Neiguan P-6, Diji Other practitioners feel that these protocols are good
signs and SP-8, Taichong LIV-3, Baihui DU-20 and Guilai ST- starting points and should also be modified based on
symptoms, and 29. After ET: Zusanli ST-36, Sanyinjiao SP-6, Xuehai the patient’s pattern diagnosis. To date, no study has
acupuncture SP-10, Hegu L.I.-4. Ear points Shenmen, Zigong compared protocols to determine which approach is
points (Uterus), Naodian (Brain), Neifenmi (Endocrine) most successful.
commonly used were used both before and after, with two of these
for treatment. points needled in each ear, and then alternated with 5. Luteal phase
the opposite ear after ET. During the luteal phase, the goal is to encourage
The Paulus (2002) protocol is not the only protocol implantation and prevent miscarriage. In natural
that has been suggested for this purpose. Liang (2003) cycles, implantation occurs approximately one
recommends before ET: Zusanli ST-36, Sanyinjiao week following fertilisation. In IVF, several days of
SP-6, Taichong LIV-3, Hegu L.I.-4, Taixi KID-3, development have already occurred in the laboratory,
Yintang, Qixue KID-13, Baihui DU-20, Sishencong M- so implantation occurs only a few days after ET. In
HN-1; Ear: Shenmen, Kidney, Liver, Spleen. After ET: terms of acupuncture, the luteal phase corresponds
Zusanli ST-36, Taixi KID-3, Yintang (M-HN-3), Baihui to yang, so supporting yang and strengthening
Journal of Chinese Medicine • Number 84 • June 2007 Acupuncture and In Vitro Fertilisation: Recent Research and Clinical Guidelines 35

its holding function is a key goal of acupuncture regular expert panel member for the National Institute
treatment. Liang (2003) recommends Baihui DU-20, of Health (NIH), National Center for Complementary
Sishencong M-HN-1, Yintang (M-HN-3), Ear: in cases and Alternative Medicine (NCCAM). She participated on
several research projects at the New England School of
of threatened miscarriage, Shenmen, Kidney, and a
Acupuncture in collaboration with Harvard Medical School.
point halfway between Liver and Spleen.
Dr Anderson is currently the Academic Dean at PCOM
One research study (Westergaard et al, 2006, Table in New York, and a practising acupuncturist and Chinese
1) investigated the use of acupuncture in the luteal herbalist. Contact: banderson@pacificcollege.edu
phase two days post-ET with the following protocol:
Baihui DU-20, Zhongji REN-3, Guilai ST-29, Xuehai
SP-10, Sanyinjiao SP-6, Zusanli ST-36, Hegu L.I.-4. The References
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at Pacific College of Oriental Medicine (PCOM) in New York, Myers ER. (2006). “Acupuncture as adjunctive Wright VC, Schieve LA, Reynolds MA,
and is a clinical supervisor at the NYU Hospital for Joint therapy in assisted reproduction: Jeng G. & Kissin D. (2004). “Assisted
remaining uncertainties,” Fertil Steril. Reproductive Technology Surveillance
Diseases’ Initiative for Women with Disabilities. She has a
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B.S. in Biological Sciences from Stanford University, is fluent 53, 1-20.
MacPherson H, White A, Cummings M,
in Mandarin Chinese, and studied and worked in Taiwan for Jobst K, Rose K, & Niemtzow R. (2001). a
Pacific College of Oriental Medicine, 915
three years. Contact: [email protected] “Standards for reporting interventions Broadway, New York, NY 10010. Ph: 212
Belinda Anderson PhD, LAc, spent 20 years as a research in controlled trials of acupuncture: 982 3456; [email protected]
scientist in molecular biology. During the past 10 years the STRICTA recommendations,”
Complement Ther Med 9(4), 246-9.
she has studied and undertaken research in Chinese
medicine. Dr Anderson has published widely and is a