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The Journal of Chinese Medicine And Acupuncture Volume 21 Issue 2 September 2014 P9
Maggie Ju. (2015) What Part Does Acupuncture Play in IVF?
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The Journal of Chinese Medicine And Acupuncture Volume 27 Issue 2 November 2020 P9
Monday, 5 October 2015
If you are diagnosed with PCOS, you are not alone. PCOS is a common ovary disorder affecting 8-10% of women in reproductive age. The symptoms include 1) many small cysts on the ovaries found in the ovary ultrasound scan; 2) irregular period cycles or no periods because of irregular ovulation or no ovulation; infertility and miscarriage; 3) excess body air or thinning hair on the head together with acne because of high levels of testosterone produced by the ovaries. 4) insulin resistance and overweight are common presentation for PCOS.
The infertility rate with PCOS is very high. Although patients with PCOS produce high number of eggs, they are often poor quality, leading to lower fertilization and implantation and higher miscarriage rate. These women have difficulty to conceive and need treatment to improve chances to get pregnant. The reduced fertility is attributed to anovulation, poor egg quality resulting from poor egg development as well as to endometrial abnormalities in women with PCOS. Contribution of endometrial abnormalities and low quality of embryos could explain the higher rate of implantation failure after induction of ovulation or higher risk of spontaneous miscarriage after pregnancy in women with PCOS.
The causes of PCOS are not fully understood. Genetic factor contributes to PCOS. Hormonal imbalance affecting follicle development and maturation is associated with PCOS. hypothalamic pituitary ovarian axis has been disturbed. Pituitary gland is more sensitive to Gonadotropin releasing hormone (GnRH) produced in hypothalamus. The hormone imbalance includes follicle stimulating hormone (FSH) deficiency, hypersecretion of luteinizing hormone (LH), high level of androgen and high blood level of insulin with insulin resistance. Women with PCOS have lower FSH compared with women without PCOS. FSH deficiency results in accumulation of smaller follicles which have undergone premature arrest and failed to become dominant follicle. Women with PCOS produce more LH during the follicular phase in their cycles. Luteinizing hormone (LH) pulse is increased in frequency and amplitude together with low follicle stimulating hormone (FSH) production. Increased LH stimulates androgen production and decreased FSH impairs follicle development, maturation and ovulation. androgen level is elevated which results in the clinical symptoms: hair overgrowth and acne. High level of androgens, are found in the blood circulation. These excessive androgens mainly produced in ovaries. A part of these androgens are produced in adrenal gland. High level of androgen is associated with increase LH level which may block dominant follicle development and cause follicular arrest and degeneration. Insulin may be involved in follicle recruitment and it may be an important mediator in follicle development. Insulin resistance may impair follicle development resulting in compromised fertility and miscarriage.
Recent research suggested that increased sympathetic nerve activity may be involved in the pathology of this condition. The greater density of sympathetic nerve fibres in polycystic ovaries has been seen and this increased ovarian sympathetic nerve activity might contribute to PCOS by stimulating androgen secretion. Women with PCOS have increased nerve growth factor (NGF) which is a strong marker for sympathetic nerve activity. Women with PCOS have increased muscle sympathetic nerve activity (MSNA), altered heart rate variability and attenuated heart rate recovery post exercises, compared with age and BMI matched controls. This suggests that there is an increased sympathetic nerve activity in women with PCOS. High testosterone was related to high sympathetic nerve activity in women with PCOS and the degree of androgen concentration can reflect the severity of PCOS which indicates that the degree of increased sympathetic activity is related to the degree of PCOS severity. Physical exercise and low frequency electroacupuncture decrease high level of sex steroid precursors, estrogen, adrgens and androgen metabolites. Physical exercises and acupuncture decreased high sympathetic activity in women with PCOS. Renal sympathetic denervation reduced MSNA and blood pressure and improved insulin sensitivity in some patients with PCOS and hypertension. Reduction of sympathetic nerve activity could be new treatment target of PCOS. Also inflammatory substances in blood increased in women with PCOS indicating the involvement of inflammation to PCOS. Stress is a risk factor of PCOS. Changing of follicular fluid microenvironment could impair egg development. Research showed that higher emotional distress was consistently found for women with PCOS compared with control populations.
There is no gold standard long term treatment for women with PCOS. For many years oral contraceptive pills played an important role in treating PCOS which normalises menstrual cycles and reduces excessive hair growth and acne. Antiadrogens also used to treat excessive hair growth. With the increasing understanding the role of insulin resistance associated with PCOS new agents-the insulin sensitizers such as metformin are introduced in the treatment of PCOS. There are other therapeutic options are emerging such as statins are a promising therapies. Vitamin D, B12 and folate may improve insulin resistance which is beneficial for women with PCOS, though this needs more research to confirm. Pharmacological treatment is effective but associated with unwanted side effects. The use of acupuncture for women’s fertility treatment becomes very common. Up to 22% of women use acupuncture for their infertility treatment in the US and about 8% in the UK. Recent research showed that acupuncture improves period cycles and ovulation as well as excessive hair and acne in women with PCOS.
Acupuncture had effect on excessive androgen and period change in women with PCOS. Polycystic ovarian syndrome (PCOS) presents hyperandrogenism which is a medical condition that is characterised by excessive production of androgen. The symptoms include high acne, excessive hair growth and high testosterone level. Less frequent or absent period and polycystic ovaries. Oral contraceptives, metformin and lifestyle change are recommended for the treatment for women who don’t want to improve fertility. Side effect could be the problems for long term treatment. People tend to seek alternative treatment for the condition. Jedel E et al studied the effect of acupuncture in women with PCOS. They allocated 84 women with PCOS aged 18-37 to three groups: acupuncture group, physical exercise group and no intervention group. 16 weeks treatment was carried out for these patients. After 16 weeks treatment, blood testosterone level and acne score were decreased, whereas menstrual frequency increased in the acupuncture group and exercise group compared to no intervention group; acupuncture group improved significantly greater than that for exercise group. Their conclusion was that both acupuncture and physical exercise had effect to treat excessive androgen and less frequent period or absent period and acupuncture had better effect than physical exercise intervention.
Polycystic ovary syndrome (PCOS) is the most common cause of anovulatory infertility. The first-line medical treatment for women with PCOS to improve fertility outcomes is clomiphene citrate. The second-line medical treatment is donadotrophins, laparoscopic ovarian surgery or metformin, if clomiphene citrate becomes resistant in women with PCOS. Because women with PCOS need prolonged treatments and these medical treatments often accompany numerous side effects. Seeking alternative treatments with less side effects could help ovulation and other symptoms. For example, lifestyle change could help infertile anovulatory PCOS in women who are overweight or obese. Clinical and experimental evidence indicates that acupuncture may be a safe alternative or complement in the treatment in women with PCOS.
A study summarized the clinical researches for PCOS treatment with acupuncture from recent years in China. The study showed that ovulation rate with acupuncture treatment was improved about 80% and pregnancy rate achieved was about 60%. Other symptoms were also improved. Stener-Victorin et al studied effect of acupuncture on ovulation in 24 women with PCOS. The result showed that 10-14 acupuncture treatments in 3 months significantly increased ovulation and period cycles in women with PCOS. There were some published randomized controlled trials which studied effectiveness of acupuncture on women with PCOS associated infertility. The results showed significantly higher pregnancy rate in the acupuncture groups compared to the control groups.
There are physiological bases that could explain why acupuncture treatment is effective on PCOS. Acupuncture stimulates autonomic nerve activities. Stimulation of peripheral nerve terminals causes release of neuropeptides which increase blood flow. Stimulation of nerves on abdomen and legs reduced sympathetic nerve activities in ovaries resulting in increasing ovary blood flow. Acupuncture stimulates peripheral nerve and the signals transmit to central nervous system. This improves function of hypothalamic-pituitary-ovarian axis, regulates blood hormone levels, increases antiinflammatory substances and improves ovary ovulation. Also acupuncture could reduce ovarian cyst size and number. Acupuncture helps reduce stress in women with PCOS.
There was study that investigated effect of acupuncture on egg quality and pregnancy rate for patients with PCOS undergoing IVF. They found that egg quality, fertilisation rate and quality of embryo were all higher in acupuncture group than that for control group with no intervention. Higher pregnant rate was achieved in acupuncture group. Acupuncture improved egg quality as well as local environment of ovaries.
PCOS increases risk of depression and anxiety and negatively affects health-related quality of life. Life style change on diet and exercise is essential and proved that this decreased depression and improved quality of life. E Stener-Victorin et al studied the effect of acupuncture and exercises on depression, anxiety and impaired quality of life in women with PCOS. 72 women with PCOS were recruited in the study. 28 women were offered acupuncture and 29 women were offered physical exercise and 15 women were assigned with no intervention. The treatments were lasted for 16 weeks for different interventions. Total 14 acupuncture treatments over 16 weeks were offered. Physical exercise program included regular exercise, such as walking, cycling or any other aerobic exercise at a self-selected pace. The frequency of exercise was at least 30 min and at least 3 times a week. This lasted 16 weeks. The assessment was at the end of 16 week treatment and 16 week follow-up after the last treatment. The results showed that depression and anxiety scores were reduced at the end of the treatment and the follow-up in the acupuncture group; the quality of life such as physical, energy/vitality, general health perception and the mental component was also improved in the acupuncture group. The quality of life such as general health perception, physical functioning and emotion was improved in exercises group.
Acupuncture is beneficial for patients with PCOS and obesity
Obesity is also associated with infertility with anovulation. It also causes pregnancy loss and late pregnancy complications. There is a link between PCOS and obesity. Women with PCOS have increased the chances of obesity and up to 66% of them are obese. Women with obesity are more likely to develop and express PCOS. PCO is present in about 20% women and many of them do not have other symptoms, such as abnormal period, acne, excessive hair growth, insulin resistance, impaired glucose tolerance, type 2 diabetes, cardiovascular diseases. These symptoms are likely to appear if the women become obese or over weight. Obesity could worsen these symptoms increasing the risk of type 2 diabetes and cardiovascular diseases. Weight loss can improve those symptoms. Preventing obesity can reduce the chances of developing PCOS. Abdominal obesity in particular is associated with anovulation and infertility. Obesity in PCOS is related to failure or delayed response to many infertility treatments. Obese women with PCOS were associated with an increased risk of miscarriage. Obese women with PCOS undergoing IVF had fewer eggs collected and lower fertilised eggs resulting in lower pregnancy rate. Study showed that after losing 5% of initial body weight obese women with PCOS improved spontaneous ovulation and spontaneous pregnancy rate. Reducing abdominal obesity is very effective to restore ovulation. Weight loss before conception also improved live birth rate in those women. Weight loss prior to start of infertility treatment can be a good option.
Research studies have shown that acupuncture can help reduce weight and improve ovulation and menstrual frequency. For example Zheng et al studied abdominal acupuncture for patients with obesity-type PCOS. They compared the effect of acupuncture with that metformin. After 6 month of treatment body mass index (BMI), waist to hip ratio (WHR), Ferriman-Gallwey score, ovarian volume, LH hormone, ratio of lLH and FSH, testosterone, LDL-C, triglycerides, total cholesterol, fasting blood glucose, 2-hour postprandial blood glucose, fasting insulin, 2-hour postprandial blood insulin, and HOMA-IR were reduced significantly in both groups. Acupuncture had better effect on reducing BMI, WHR and increasing menstrual frequency and had fewer side effects compared with those with metformin.
Lai et al studied the effect of acupuncture on polycystic ovarian syndrome (PCOS). There were 86 patients with PCOS and obesity involved in the study. These patients were divided into two groups: acupuncture group and metformin group. In acupuncture group the patients received abdominal acupuncture for 6 months. Body mass index (BMI), waist-hip ratio (WHR), Ferriman-Galleey score (FGS) which is the method to assess overgrowth hair, menstrual frequency (MF), ovarian volume (OV) were measure and compared before and after the treatments. Hormonal levels including follicle stimulating hormone (FS), luteinizing hormone (LH), testosterone hormone were tested as well. In addition fasting blood glucose and insulin, insulin resistance and blood lipid levels (LDL and HDL) were tested. As a result, they found that BMI, WHR, FGS and OV were significantly reduced after treatment in both groups (acupuncture group and metformin group). Menstrual frequency was significantly increased after treatment in both groups. Hormone levels including LH, LH/FSH and testosterone were decreased after treatment in both groups. Fasting blood sugar and insulin, insulin resistance and LDL were decreased, while HDL was increased in both groups. They concluded that acupuncture was beneficial for patients with PCOS and obesity.
Acupuncture could increase insulin sensitivity and reducing blood sugar levels; it also reduces cortisol levels and helps weight loss and eating disorders. Insulin resistance is closely linked to obesity, type 2 diabetes, hypertension, PCOS etc. Liang F and Koya D analysed 234 publications in English from 1979 to 2009 on the effect of acupuncture for the treatment of insulin resistance. These literatures provided evidence to support the effectiveness of acupuncture for treating insulin resistance.
Current opinions on effect of acupuncture to treat PCOS
Recently Lim CE and Wong WS did a review to investigate the effect of acupuncture on polycystic ovary syndrome (PCOS). They obtained and assessed all available acupuncture studies on women with PCOS from June 1970 to June 2009. From this review they found that acupuncture is effective for PCOS treatment. Several studies showed that acupuncture increased beta-endorphin levels which last up to 24 hours; acupuncture may affect hormone levels including follicle stimulating hormone (FSH), luteinizing hormone (LH) and androgen. Acupuncture affects the hypothalamic-pituitary-adrenal axis to contribute to reducing stress. They concluded that acupuncture is a safe and effective treatment for PCOS and no side effects were found. The possible mechanism of the acupuncture treatment of PCOS includes increasing ovarian blood supply, reducing ovarian volume and ovarian cyst numbers. Acupuncture could increase insulin sensitivity and reducing blood sugar levels; it also reduces cortisol levels and helps weight loss and eating disorders. Insulin resistance is closely linked to obesity, type 2 diabetes, hypertension, PCOS etc. Liang F and Koya D analysed 234 publications in English from 1979 to 2009 on the effect of acupuncture for the treatment of insulin resistance. These literatures provided evidence to support the effectiveness of acupuncture for treating insulin resistance.
Stress is a risk factor for PCOS and acupuncture helps to reduce stress
Polycystic ovary syndrome (PCOS) is a common cause of anovulation leading to infertility. A research analysis showed that emotional distress is a common risk in women with PCOS. This conclusion was drawn from meta-analysis of 28 studies from Veltman-Verhulst SM et al in University Medical Center Utrecht, The Netherlands. They examined emotional distress and its association in women with PCOS. The data was obtained up to November 2011. 28 studies included 2384 patients with PCOS and 2705 women in control population. Higher emotional distress was consistently found for women with PCOS compared with control populations, though distress scores mostly remain within the normal range. More recently Murri M et al analysed data up to June 20120 to study oxidative stress and PCOS. Their results were from 1633 studies including 4933 patients with PCOS and 3671 controls. They found that patients with PCOS have higher circulating markers of oxidative stress compared with controls. Oxidative stress may contribute to the pathophysiology of PCOS.
Acupuncture was effective to treat PCOS and acupuncture was also effective to reduce stress. Research showed that 8 weeks acupuncture intervention could help reduce infertility related stress. Acupuncture treatments help change social and relationship concern and reduce anxiety. They felt more relaxed than those without acupuncture treatment.
Recently there is another study on acupuncture for PCOS. In this study, 101 women with PCOS participated. The main acupuncture points used were Zhibian (BL54) and Shuidao (ST28) together with other acupuncture points which chosen individually. After 5 courses of acupuncture treatments basal body temperature was improved and the follicle-stimulating hormone (FSH), luteinizing hormone (LH), LH/FSH and testosterone (T) were significantly reduced.
New research shows acupuncture increases ovulation frequency in women with PCOS
Am J Physiol Endocrinol Metab 2013 published a paper titled Acupuncture for ovulation induction in polycystic ovary syndrome (PCOS): A randomized controlled trial. This research has been done by Stener-Victorin E group. They investigated the effects of acupuncture on ovulation frequency and the mechanism. 32 women with PCOS participated the research. Acupuncture performed twice a week for 10-13 weeks. Previously acupuncture has already been proven to improve menstrual frequency and decrease circulating testosterone in women with PCOS. After 13 weeks of intervention, luteinizing hormone (LH) secretion patterns were changed. Ovulation frequency was higher in acupuncture group compared with control group. Ovarian and adrenal sex hormones Levels decreased significantly in acupuncture group compared with control group.
PCOS takes place when the normal cycle is disrupted due to anovulation. This creates hormonal imbalance with increased oestrogen and androgen in the circulation and without progesterone. Acupuncture increases ovulation frequency and restore hormonal balance.
There are about 10-20% of women have PCOS. The conventional treatments include using birth control pills to inhibit hormone production and using new drugs like metformin a type II diabetes agent to lower insulin resistance. However these treatments are not particularly successful with many side effects. Acupuncture is a promising approach to treat PCOS.
Raja-Khan N et al Am J Physiol Endocrinol Metab (2011) 301:E1-E10.
Jedel E et al Am J Physiol Endocrinol Metab (2011)
Stener-Victorin E et al Ata Obstet Gynecol Scand (2000) 79:180-8
Cui W Zhongguo Zhen Jiu (2011) 31:687-91
E Stener-Victorin et al BMC Complement Altern Med (2013) 13:131
Alexandra Bargiota and Evanthia Diamanti-Kandarakis Ther Adv Endocrimol Metab (2012) 3:27-47
Lai MH et al Zhen Ci Yan Jiu (2010) 35:298-302
Lim CE and Wong WS Gynecol Endocrinol (2010) 26:473-8
Liang F and Koya D Diabetes Obes Metab (2010) 12:555-69
Veltman-Verhulst SM et al Hum Reprod Update (2012) 18:638-51
Murri M et al Hum Reprod Update (2013) Jan 16
Zheng YH et al J Altern Complement Med (2013) 19:740-5
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