Acupuncture and Infertility Treatment: Is There More to the Outcome for Women than Pregnancy?

Introduction

Infertility is a distressing experience that affects ∼9% of couples at any one time. ¹ Infertility is the failure to become pregnant after 12 or more months of regular unprotected sexual intercourse. ² While in-vitro fertilization (IVF) is recognized worldwide as an established treatment for infertility, this is a complex and invasive process that involves several discrete steps, with each step carrying its own possibility of failure.

In addition to the physical hurdles, there is evidence that women's responses to infertility and unsuccessful treatment produce significant psychologic morbidity. Infertile women are still perceived as deviating from the expected course of pregnancy and motherhood ³ and these women experience a great deal of pressure to conform. Emotional responses to infertility have been linked with grief, depression, anxiety, and chronic stress. ⁴ Furthermore, such emotional morbidity may affect the outcome of IVF. ⁵

In Australia and New Zealand, recent estimates indicate that 3.2% and 2.0% of all women who gave birth in Australia and New Zealand, in 2008, respectively, were the result of some form of assisted reproductive technology (ART) treatment. ² However, despite steady progress in increasing pregnancy and live birth rates, only 17.2% of live births were achieved from more than 70,000 treatments.

Research shows that distress among women undergoing IVF increases over time. Many women experience IVF treatment as being extremely stressful ⁶ and seek information and alternative means of enhancing their chances for pregnancy and live birth.^7–11

While common to China and arising from ancient origins, acupuncture as a therapy for infertility is relatively recent to Western women's health care such as that offered by ART clinics in Australia. In 2002, there was a surge of interest in complementary therapies as an adjunct to IVF/intracytoplasmic sperm injection (ICSI) when Paulus et al. ¹² reported that the pregnancy rate improved significantly when acupuncture was added to treatment regimens at the time of embryo transfer (ET) in infertile women. The decision to recommend acupuncture during IVF moved forward following the publication of a systematic review ¹³ and a Cochrane review. ¹⁴ Both reviews reported a benefit of acupuncture at the time of ET and this benefit was associated with improved clinical pregnancy rates. ¹⁵

There are now more than forty clinical studies evaluating the role of acupuncture administered as an adjunct to IVF, and there are eight systematic reviews and meta-analyses of randomized controlled trials (RCTs) examining if acupuncture can improve pregnancy and live birth outcomes. Some reviews reported positive outcomes, while others concluded that there is no evidence of benefit. These differing conclusions may have resulted from the different research inclusion and exclusion criteria of trials, and the inclusion of trials addressing different research questions. Even while studies have suggested that acupuncture can enhance fertility effectively when used as an adjunct to IVF/ICSI, these conflicting trial results make the clinical decision of whether or not to recommend acupuncture to women during IVF unclear. ¹⁵

Despite the tension around the yet-unproven promise of acupuncture to help infertile women get pregnant more quickly when using IVF/ICSI, acupuncture has become popular and increasingly widespread among women undergoing IVF/ICSI. Although uncertainty remains in medical circles about this modality, acupuncture has received considerable attention in both the lay and scientific media. ¹⁶ Many infertile women have reported exposure to information about alternative remedies^7,8 through various means, such as surfing the Internet or acupuncture being recommended by a friend, physician, or counselor. In 2012, when the current authors entered the search terms acupuncture and IVF into Google, this yielded 2,880,000 hits. These were the websites of various ART clinics, natural-therapy centers offering acupuncture for infertility and IVF support, news broadcasts refuting the benefits of acupuncture, You-Tube footage of women's narratives of how acupuncture helped them become pregnant, and infertile women themselves posting blogs about using acupuncture to improve their chances of becoming pregnant and recommending acupuncture to their friends, who were equally successful. This suggests that acupuncture may mean more in women's health care than an intervention with respect to improving treatment outcomes.

Many infertile women experience powerlessness when control over their fertility is taken “out of their hands” during IVF/ICSI treatment.^7–9,17 This article addresses the question: “Do women feel empowered through the choice and use of acupuncture during treatment—whether pregnancy is achieved or not?”

Acupuncture and Empowerment

In an article about having acupuncture in the United Kingdom, Rowan Pelling ¹⁸ described how acupuncture felt as if a strong blockage had been removed “after the first treatment, when I felt currents of energy move across my body, something very strange happened. I not only felt as if a portcullis somewhere inside had lifted but I ovulated for a second time that month.”

In studies of women's experiences of acupuncture in infertility and assisted reproductive technology (ART), similar experiences have been reported. Women have reported experiencing feelings of release, feeling less “uptight,” and feeling more energized and thereby able to cope.^8,9

Most importantly, for women experiencing infertility and undergoing IVF, acupuncture was a choice that these patients made for self-care; for improving their health, vitality, and fertility (even in the face of absolute infertility), and for enhancing their chances of pregnancy and live birth using a medical procedure.^7–9,17,19 This choice was considered and proactive, and women experienced empowerment through doing something to help themselves rather than just waiting passively to see how things turned out. Women described feeling disempowered by the medical process of ART and how, through acupuncture, they came to feel “better in themselves,” “more confident,” “healthier,” “more alive,” “refreshed,” “tolerant,” and “emotionally more in control.” ⁸ An important theme in several studies is women's expression of regaining control of their bodies^4,8,9,17 and experiencing a change in perspective about their infertility.^4,8 For example, a woman participant in Rayner et al.'s ⁹ study reported: “Actually, doing acupuncture was something additional that I'd chosen to do and I felt some control as a result of doing that.”

In the current authors' first qualitative study (with another colleague) ⁸ restoring personal power was a major theme in which women described a process of relinquishing their bodies to medical treatment and then feeling as if they'd “taken them back” through choosing an adjunct treatment that centered their whole selves and concentrated on enhancing their wellness. For instance one participant (subject 8) said that “[acupuncture] made me think that you had a little bit of power because you were doing something proactive—without just waiting, having those things done to you and then just waiting. You were actually doing something to help.”

As this participant suggested, feelings of empowerment were gained not only through regaining control over her body and her emotions, but from taking steps that she believed would enhance her chances of a successful outcome. In this study, ⁸ women perceived that acupuncture could enhance their chances of achieving pregnancy without diminishing the effects of medical interventions. Women perceived the potential for acupuncture to increase their chances of success as being very high. Although the women were unable to say confidently that acupuncture was linked to the positive outcome of pregnancy, they were convinced that acupuncture “was the key” and that it had helped them through relaxation and increased well-being. ⁸

Alfred and Ried ¹⁷ reported that women who participated in their qualitative study felt both informed and empowered through a process of treatment that combined acupuncture with Chinese herbal medicine. Women expressed the empowerment they perceived when they received information and gained a better understanding of fertility indicators. One participant (ID 19) commented: “They could do more before you start that IVF process to empower you…rather than you feeling you're just a cog in the machine.…I just felt I was getting tossed around in the wind.”

In several studies, the relationships between the acupuncturists and women, and the holistic approach of acupuncture enhanced women's sense of empowerment. In contrast to what women experienced during their medical regimens, these patients perceived the less-paternalistic approach of acupuncture to be empowering, because it increased their feelings of trust and control.^{4,7–9,17,19}

Moreover, women felt that they had done everything possible to achieve pregnancy and live birth.^4,8,9,19 This is clearly an important component of empowerment for women. In Porter et al.'s study of information-seeking, women who became pregnant viewed their own efforts in helping themselves as having contributed to the positive outcome. Porter et al. ⁷ reported that women who were active and successful participants in their treatment were able to regain control over their stressful situation. Women were empowered by the experience of contributing, with 1 participant (Female 118) noting that “it makes you feel empowered because you're doing something. You are being proactive about it instead of feeling like this is happening to [you], you know.”

Discussion

While attention has been focused on the ability of acupuncture to increase a woman's chance for pregnancy in the absence of—or during—medical treatment, little attention has been paid so far to the impact of acupuncture on the health of infertile women from a broader, holistic perspective. These findings from these individual studies demonstrate the strength of qualitative research for reflecting the broader outcomes achieved by acupuncture and other complementary medicine treatments, and highlight the broader improvements in well-being that can arise from research that reflects actual clinical practice. This review of literature found that acupuncture had a profound effect on women's lives through its capacity to empower them and thereby offer opportunities for improving women's health whether or not they achieve the outcome of pregnancy.

Empowerment was reported as emerging from women taking an active—rather than passive—role in medical interventions that they underwent, and empowerment resulting from women taking charge of their bodies and their psychologic and physical health. Other positive effects of acupuncture were also evident, however. Studies also reported women as feeling relaxed, energized, and less stressed. Undoubtedly, these effects also contributed to increased personal empowerment. This impact of acupuncture was also found in other studies that were not related to infertility, for instance in studies of the effect of acupuncture on people living with chronic disease. Cassidy reported “expanded effects of care” in 460 users of acupuncture and Chinese herbal medicine. This related to outcomes such as increases in energy, relaxation, and calmness; improvements in psychosocial coping, such as increased self awareness, balance, centeredness, and well-being; and increases in self-efficacy and feeling more able to guide their own lives and care for themselves. ²⁰ Similarly, in a study of acupuncture for low-back pain MacPherson et al. ²¹ reported the active engagement of patients in their own recovery as an outcome of the acupuncture treatment.

Within the last 6 years, a new paradigm of fertility care has been proposed that includes an assessment and management of lifestyle interventions. ²² Ockhuijsen et al. ²³ demonstrated that couples attending an IVF program can be motivated to receive preconceptual care that involves lifestyle interventions. However, these researchers reported poor compliance and dropouts from exercise and dietary interventions. This review opens the possibility that women empowered by acupuncture treatment in preconceptual programs may be able to establish and sustain healthier behaviors (e.g., regular exercise, good eating habits) and modify unhealthy habits (e.g., by stopping smoking).

Conclusions

In Australia, the National Women's Health Policy names sexual and reproductive health as one of the priority health issues for women in Australia, including fertility and infertility. ²⁴ Many women's health centers have the understanding that empowering women is a key to well-being and is an essential component of women's health care.^24–26

The word empowerment has many meanings associated with it, but, as a strategy, it has been a very effective tool for women's health. Through using education and affirmative action, leaders of women's health movements have empowered women who are marginalized because of gender, race, sexuality, and disability, among other factors. It has been argued that “fertility” should be on this list, because infertile women are socially marginalized as a result of being unable to become mothers and are subsequently isolated socially. ²⁷ Medical treatments for infertility necessarily require that patients be passive recipients rather than active participants in these treatments, because complex procedures, such as IVF/ICSI, involve highly regulated physical processes. However this treatment further marginalizes and disempowers these patients. Stress and reproductive failure have been linked together empirically, ²⁸ so reducing stress in treatment is an important goal.

There is emerging evidence that acupuncture, among other complementary therapies, offers a way for infertile women to help themselves and experience enjoyment, rejuvenation, and empowerment. This empowerment is the process by which women are offered reduction of stress, alternative opportunities for good health and (re)becoming a whole person, and a sense of peacefulness and well-being, despite the chaotic (as perceived by patients) and disempowering nature of IVF/ICSI treatment. Ultimately, acupuncture empowers infertile women to be active in their treatment and thereby influences its outcome. However, even if the desired outcomes of pregnancy and live birth are not achieved, through taking action and through the holistic approach of acupuncture, women experience personal empowerment.

Disclosure Statement

The authors have no conflict of interest to declare.