What is acupuncture?
While many people may be familiar with acupuncture, they often do not understand what makes it potentially effective as a treatment. The insertion of small acupuncture needles into acupuncture points is believed to stimulate different aspects of the nervous and endocrine systems.ii It is a clinically accepted therapy for the treatment of numerous conditions, including back painiii and osteoarthritis.iv
People also seek acupuncture for the improvement of reproductive health. It has been shown to provide potentially effective treatment for female reproductive disorders, including dysmenorrheav and premenstrual symptoms.vi Acupuncture may improve female reproductive health by increasing blood flow to the uterus and ovaries,vii regulating levels of fertility hormones,viii and influencing beta-endorphin production, which could help patients with PCOS.ix
How does acupuncture improve fertility?
Acupuncture research is more often focused on final outcomes rather than the mechanisms of action (how it works). Therefore, it is often not clear how acupuncture affects the physiology of the body and impacts fertility. What is known about some of these mechanisms is discussed here
Female fertility
Optimal levels of follicle stimulating hormone (FSH), luteinizing hormone (LH), and estradiol are important in the regulation of the female uterine (menstrual) cycle and for IVF success. There is evidence supporting the idea that acupuncture treatment can lower FSH and LH levels, as well as increase estradiol levels in females with premature ovarian insufficiency (POI).x
Reviews of the published literature report that acupuncture can modulate hormones, such as estrogen, progesterone, and prolactin in individuals with gynecological or reproductive issues. Researchers conclude that the neuroendocrine system (nervous and hormonal system) can be impacted by acupuncture treatment and that more research in this area is warranted.xi
Acupuncture has also been associated with improvement in endometrial receptivity as well as improvement in endometrial morphology, by promoting microcirculation inside the uterus and regulating progesterone levels and receptor expression.xii When used for individuals with poor endometrial receptivity, the positive impact appeared to grow with an increasing number of acupuncture sessions (i.e., weekly sessions for three menstrual cycles versus two acupuncture sessions).xiii These improvements, however, have not reliably resulted in improved pregnancy or live birth rates.
Male fertility
As in females, abnormal levels of FSH and LH in males can decrease male fertility. They do so by altering testosterone levels, spermatogenesis, or even impacting the seminiferous tubule lining (epithelium) and mesenchymal cells.xiv Animal studies have suggested that acupuncture can potentially shift hormone levels in males by helping to reduce FSH and LH, and to increase testosterone levels.xv,xvi However, it is unclear whether this effect is applicable to humans.
Furthermore, acupuncture may improve fertility in individuals with male factor fertility related to sperm parameters.xvii There is evidence to support the idea that sperm concentration, density, morphology, viability, and motility of sperm is significantly higher after acupuncture treatment in males with low sperm counts.xviii,xix It is hypothesized that acupuncture may cause these improvements by increasing testicular blood flow and/or reducing genital inflammatory reactions by promoting a more balanced immune system. However, the mechanism of action related to improving sperm parameters remains unclear and these improvements do not necessarily result in higher pregnancy or live birth rates.xx
Acupuncture for fertility: Research evidence
Acupuncture became much more popular in the North American fertility market in 2009 after a small study published in the journal of Fertility and Sterility showed an increase in pregnancy rates in individuals who had acupuncture before and after in vitro fertilization (IVF) transfer.xxi
This study was criticized for not having a type of control arm called a "sham treatment.” In general, sham treatments are used in studies to “blind” patients from knowing whether they are in the treatment or control arm of the study. Sham treatments can be designed where patients receive acupuncture at non-treatment points. Sham needles, which do not penetrate skin but feel like typical acupuncture treatment, can also be used.xxii
The same researchers later presented results from a prospective study using a sham control arm, showing no significant difference in clinical pregnancy rates between the acupuncture and sham groups.xxiii The authors noted that the sham acupuncture treatments may still be offering some benefit and that the difficulty in assessing acupuncture effectiveness may be the lack of a good type of control arm in studies.xxiv Since 2009, there has been research of varying quality to assess the role of acupuncture in both male and female fertility.
Acupuncture for female fertility: Research evidence and success rates
It is difficult to determine the efficacy of acupuncture for fertility because of the conflicting study results, small sample sizes, and heterogeneity in study methodologies (e.g., different fertility conditions, patient populations, etc.). The more recently published scientific evidence available is summarized below.
A 2019 systematic review and meta-analysis by Zhong and colleagues showed that acupuncture may slightly improve pregnancy rates, increase the likelihood of a trilaminar uterine lining (triple-line pattern) on ultrasound, and slightly thicken endometrium.xxv Although these were statistically significant findings, the quality of research they analyzed was considered to be low.xxvi Furthermore, the studies included had a variety of different control arms, making comparison difficult across studies.
A much larger 2021 review analyzed previous systematic reviews and published randomized control trials (RCTs) and noted that the reliability of previously published study results is poor because the overall quality of studies and reviews was very low.xxvii They concluded that the evidence to support acupuncture in IVF and embryo transfer cycles is insufficient, but that nonetheless it appears that acupuncture may be able to increase the clinical pregnancy rate in females undergoing embryo transfers.xxviii
Another systematic review involving eight RCTs with 3,607 females assessed acupuncture around the time of embryo transfer.xxix They found no statistically significant difference in acupuncture treatment versus placebo acupuncture with respect to clinical pregnancy rates or live birth rates.xxx
One well-conducted randomized controlled trial of 824 females undergoing IVF in Australia and New Zealand compared a sham treatment to acupuncture treatment with points to stimulate blood flow to the uterus, to inhibit central nervous system outflow, and to inhibit biological stress response.xxxi The sham treatment used the Park device, whereby the control group receives non-insertive acupuncture using the Park sham needle, which does not penetrate the skin.xxxii They found no significant difference in patients undergoing fertility treatments versus sham treatment; live birth rates were not significantly different in the acupuncture group (three treatments) versus the control (sham) group.xxxiii
Poor ovarian response (POR)
Research on acupuncture in females with poor ovarian response is limited. One pilot randomized controlled trial (RCT) by Kim et al (2020) showed that acupuncture before IVF treatment had beneficial effects in patients with a diagnosis of poor ovarian response. However, there were only 18 patients and it was a non-blinded RCT, so the reliability of results is unclear.xxxiv
A review by Jang et al (2020) analyzed three RCTs involving acupuncture treatment in poor responders undergoing IVF.xxxv The authors observed improvements in several fertility parameters; however, the data was limited, and the authors note that it is difficult to conclude that IVF with acupuncture is more effective than IVF without acupuncture. Among the three RCTs reviewed, authors found improvements in clinical pregnancy rate, anti-Müllerian hormone (AMH), antral follicle count (AFC), and number of retrieved oocytes.xxxvi
Recurrent implantation failure (RIF)
There is also limited data on the effects of acupuncture in patients with recurrent implantation failure (RIF). A 2021 meta-analysis of patients with RIF showed that endometrial thickness and clinical pregnancy rate were improved in the acupuncture treatment group compared to the control groups.xxxvii However, the authors note caution in the reliability of the results due to the lower quality of the studies included.xxxviii
Polycystic ovary syndrome (PCOS)
Usage of acupuncture in patients with PCOS also has mixed evidence in studies of varying degrees of quality.xxxix,xl,xli,xlii As such, the efficacy of acupuncture on pregnancy outcomes in PCOS patients is unclear, with some studies showing improvement and others showing no improvement in outcomes. A 2019 systematic review and meta-analysis of eight RCTs comprising 1,546 females concluded that the evidence was not sufficient to determine the effectiveness of acupuncture for PCOS.xliii
Acupuncture for male fertility: Research evidence and success rates
The first known study of acupuncture outside of Asia on male fertility was conducted in 1984 by Riegler and colleagues,xliv and it observed some improvement in sperm parameters. Since this time, however, various studies have been conducted to assess the effects of acupuncture on semen parameters with mixed results.
In a 2021 systematic review and meta-analysis of seven studies with 527 subjects, acupuncture did not improve sperm parameters in patients with reduced sperm motility (asthenospermia) and low sperm count (oligospermia).xlv The authors suggested that, due to poor research quality, they could not conclude that acupuncture was helpful in improving sperm quality.xlvi
Another review examined four randomized controlled trials and observed some improvement in sperm motility and concentration.xlvii However, the authors noted that the evidence was not sufficient to support acupuncture treatments for semen improvement due to inconsistency in studies, insufficient evidence due to few studies, high risk of bias, and poor quality of tracking outcomes.xlviii
In sum, despite numerous studies investigating acupuncture and infertility (in both females and males), it is unclear whether acupuncture provides any benefit for patients undergoing fertility treatment. For example, some studies lack control arms, many have small sample sizes, and lack a sufficient number of treatments, which results in insufficient conclusions.xlix
Acupuncture success rates for natural conception
A small study of 56 females in Australia compared individuals using lifestyle modifications to improve chances of conception versus people who also used acupuncture. They found that acupuncture positively influenced the females who received it compared to the individuals who used lifestyle modification alone. Acupuncture increased their fertility awareness, improved their feelings of well-being, and decreased the time to pregnancy. More specifically, those who conceived did so in half the time (5.5 weeks) compared to those who only modified their lifestyle (10.67 weeks); however, this difference was not statistically significant, and a one-month disparity is equally likely due to physiological differences or chance, as opposed to treatment intervention.l
Risks of acupuncture for fertility
One study in the British Medical Journal reported that acupuncture can be considered safe.li Serious adverse events are rare at a rate of 1.01 per million treatments, and potentially include pneumothorax, fainting, and falling.lii The most common minor adverse events are very mild, such as bleeding, pain or flare at the needle site, and hematomas (bruises).liii,liv
Where to get acupuncture for fertility
Any healthcare provider licensed to do acupuncture could, in theory, treat infertility patients with a specific fertility methodology. However, it is important to seek treatment with someone who has experience. Acupuncture is often discussed at fertility clinics, and those clinics may have experts onsite who can perform acupuncture. Naturopathic doctors who provide acupuncture may also discuss diet and supplements to help with fertility. In addition to acupuncture, other traditional Chinese medicine (TCM) practices such as herbal remedies and dietary recommendations may be offered.
Conclusion
For individuals looking for an alternative form of treatment for fertility issues, or an add-on to assisted reproductive technology (ART) treatment, acupuncture may be worth considering. Though acupuncture is not a guaranteed solution (it has limited evidence and mixed results), it has helped some patients pursuing improved fertility achieve positive results.
i Rayner, J. et al. (2011). Women’s Use of Complementary and Alternative Medicine for Fertility Enhancement: A Review of the Literature. Journal of Alternative and Complementary Medicine, 17(8), 685–690. https://doi.org/10.1089/acm.2010.0435
ii Stener-Victorin, E., & Wu, X. (2010). Effects and mechanisms of acupuncture in the reproductive system. Autonomic neuroscience : basic & clinical, 157(1-2), 46–51. https://doi.org/10.1016/j.autneu.2010.03.006
iii Liu, Y. et al. (2015). Efficacy and Safety of Acupuncture for Acute Low Back Pain in Emergency Department: A Pilot Cohort Study. Evidence-Based Complementary and Alternative Medicine, 2015, 1–8. https://doi.org/10.1155/2015/179731
iv Chen, J. et al. (2021). Acupuncture for the Treatment of Knee Osteoarthritis: An Overview of Systematic Reviews. International Journal of General Medicine, Volume 14, 8481–8494. https://doi.org/10.2147/ijgm.s342435
v Hye Lin Woo et al. (2018). The efficacy and safety of acupuncture in women with primary dysmenorrhea. Medicine, 97(23), e11007–e11007. https://doi.org/10.1097/md.0000000000011007
vi Zhang, J.-Y. et al. (2019). Acupuncture for Premenstrual Syndrome at Different Intervention Time: A Systemic Review and Meta-Analysis. Evidence-Based Complementary and Alternative Medicine, 2019, 1–9. https://doi.org/10.1155/2019/6246285
vii Elisabet Stener-Victorin et al. (2006). Ovarian blood flow responses to electroacupuncture stimulation depend on estrous cycle and on site and frequency of stimulation in anesthetized rats. Journal of Applied Physiology, 101(1), 84–91. https://doi.org/10.1152/japplphysiol.01593.2005
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ix Danforn CE Lim et al. (2011). Acupuncture for polycystic ovarian syndrome. Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.cd007689.pub2
x Cochrane, S. et al. (2016). Prior to Conception: The Role of an Acupuncture Protocol in Improving Women’s Reproductive Functioning Assessed by a Pilot Pragmatic Randomised Controlled Trial. Evidence-Based Complementary and Alternative Medicine, 2016, 1–11. https://doi.org/10.1155/2016/3587569
xi Elisabet Stener-Victorin, & Wu, X. (2010). Effects and mechanisms of acupuncture in the reproductive system. Autonomic Neuroscience, 157(1-2), 46–51. https://doi.org/10.1016/j.autneu.2010.03.006
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xl Xu, W. et al. (2020). Clinical effects of Shou-Wu Jiang-Qi Decoction combined acupuncture on the treatment of Polycystic Ovarian Syndrome with kidney deficiency, phlegm and blood stasisness. Medicine, 99(12), e19045–e19045. https://doi.org/10.1097/md.0000000000019045
xli Zheng, R. et al. (2021). The Effect of Acupuncture on Glucose Metabolism and Lipid Profiles in Patients with PCOS: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Evidence-Based Complementary and Alternative Medicine, 2021, 1–11. https://doi.org/10.1155/2021/5555028
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xlviii Ui Min Jerng et al. (2014). The effectiveness and safety of acupuncture for poor semen quality in infertile males: a systematic review and meta-analysis. Asian Journal of Andrology, 16(6), 884–884. https://doi.org/10.4103/1008-682x.129130
xlix Zheng, C., et al. (2020). General Issues in Clinical Research of Acupuncture and In Vitro Fertilization. Evidence-Based Complementary and Alternative Medicine, 2020, 1–5. https://doi.org/10.1155/2020/3460641
l Cochrane, S. et al. (2016). Prior to Conception: The Role of an Acupuncture Protocol in Improving Women’s Reproductive Functioning Assessed by a Pilot Pragmatic Randomised Controlled Trial. Evidence-Based Complementary and Alternative Medicine, 2016, 1–11. https://doi.org/10.1155/2016/3587569
li Bäumler, P. et al. (2021). Acupuncture-related adverse events: systematic review and meta-analyses of prospective clinical studies. BMJ Open, 11(9), e045961–e045961. https://doi.org/10.1136/bmjopen-2020-045961
lii Bäumler, P. et al. (2021). Acupuncture-related adverse events: systematic review and meta-analyses of prospective clinical studies. BMJ Open, 11(9), e045961–e045961. https://doi.org/10.1136/bmjopen-2020-045961
liii Bäumler, P. et al. (2021). Acupuncture-related adverse events: systematic review and meta-analyses of prospective clinical studies. BMJ Open, 11(9), e045961–e045961. https://doi.org/10.1136/bmjopen-2020-045961
liv Eung, C. et al. (2019). Acupuncture for polycystic ovarian syndrome. The Cochrane Library. https://doi.org/10.1002/14651858.cd007689.pub4
lv Eung, C. et al. (2019). Acupuncture for polycystic ovarian syndrome. The Cochrane Library. https://doi.org/10.1002/14651858.cd007689.pub4