Interpretation
Our review suggested that the pooled CPR and LBR from all the
acupuncture group were significantly higher than that from all the
control group (p < 0.001). It was consistent with the studies
reported by Manheimerand E et al (2008) (8) and Zheng CH et al (2012)
(9). However, when restriction to only low risk of bias studies, there
was no benefit of TA method on CPR and LBR. It suggested that we should
caution against the benefits of TA being overstated. Of note, when only
low risk of bias studies were included, a change to a non-significant
effect did occur for TEAS. Because of the later published time, TEAS
intervention did not involve in the existed reviews and this was the
first time to report the pooled effect of TEAS. The results of TEAS is
of great clinically significance for IVF, based on its advantages of
noninvasiveness and painlessness, TEAS may have better application
potential and be more acceptable. The safety of TEAS may be better than
TA, because the MR was not significant between TEAS and no treatment.
Meanwhile, unlike TA method, sham TEAS is easy to be implemented by
”pseudo-percutaneous patch” method.
In our meta-analysis, TA did not increase the CPR compared with sham
acupuncture, whether or not the sham needles were penetrated. This was
consistent with a growing concern that sham acupuncture was not an inert
control and may result in the difference between intervention and sham
group not being significant. Regardless of either true or sham
acupuncture was used, they could both produce specific effects and
non-specific effects. The non-specific effects between treatment and
sham acupuncture may be reduced to the greatest extent through blind and
random methods. Therefore, in order to improve the reliability, an
appropriate control group should be selected by the specific study
objective like examining the pragmatic or comparative effectiveness
(22).
In our study, differences were seen when different acupuncture sessions
were analyzed. A dosage of ≥3 times for TA and TEAS were both associated
with statistically significant improvement on CPR and LBR. Many trials
tended to use two or a maximum of three sessions of acupuncture, such as
“Paulus acupuncture protocol” performed just twice with one before and
another after ET (57). Insufficient acupuncture dosage in IVF has been a
common opinion (78). Some investigators suggested that a clinically
valid dosage of acupuncture should be more than six acupuncture sessions
and at least choose four to ten (or more) acupuncture points in each
session (79). Further study should explore the specific effective dose
of acupuncture treatment.
Our review analyzed all common acupuncture types in IVF treatment based
on the most comprehensive trials. The results of TEAS supply a superior
and safe choice for patients and physicians, especially compared with
manual acupuncture, its advantages of noninvasiveness and easier
administration partly reduce the involvement of many confounding factors
cause by acupuncturists. Therefore, it may be a promising IVF adjunctive
treatment and has broader application after being validated by strict
RCTs. We also found that less than 35 years, treatment with ≥3 sessions,
acupuncture before the ET, no RIF history and lower baseline pregnancy
rates were associated with increases in CPR and LBR. These results were
greatly helpful for the design of further acupuncture treatment trials
in IVF. In addition, LBR should be considered as a primary outcome of
the further IVF meta-analysis study. It was undeniable that clinical
pregnancy was a major breakthrough in medicine, but for infertile
couples, “take-home” babies were the most important long-term and
ultimate outcome of interest (25, 26). Moreover, the efficacy was
significant just for CPR rather than LBR, which may indicate a higher
risk of miscarriage. This not only increased the patients’ economic
burden, but also further resulted in psychological consequences.