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. 2019 Jul 2;7(7):CD007689.
doi: 10.1002/14651858.CD007689.pub4.

Acupuncture for polycystic ovarian syndrome

Chi Eung Danforn Lim  1 , Rachel Wai Chung Ng, Nga Chong Lisa Cheng, George Shengxi Zhang, Hui Chen
Affiliations

Acupuncture for polycystic ovarian syndrome

Chi Eung Danforn Lim et al. Cochrane Database Syst Rev. .

Abstract

Background: Polycystic ovarian syndrome (PCOS) is characterised by the clinical signs of oligo-amenorrhoea, infertility and hirsutism. Conventional treatment of PCOS includes a range of oral pharmacological agents, lifestyle changes and surgical modalities. Beta-endorphin is present in the follicular fluid of both normal and polycystic ovaries. It was demonstrated that the beta-endorphin levels in ovarian follicular fluid of otherwise healthy women who were undergoing ovulation were much higher than the levels measured in plasma. Given that acupuncture impacts on beta-endorphin production, which may affect gonadotropin-releasing hormone (GnRH) secretion, it is postulated that acupuncture may have a role in ovulation induction via increased beta-endorphin production effecting GnRH secretion. This is an update of our previous review published in 2016.

Objectives: To assess the effectiveness and safety of acupuncture treatment for oligo/anovulatory women with polycystic ovarian syndrome (PCOS) for both fertility and symptom control.

Search methods: We identified relevant studies from databases including the Gynaecology and Fertility Group Specialised Register, CENTRAL, MEDLINE, Embase, PsycINFO, CNKI, CBM and VIP. We also searched trial registries and reference lists from relevant papers. CENTRAL, MEDLINE, Embase, PsycINFO, CNKI and VIP searches are current to May 2018. CBM database search is to November 2015.

Selection criteria: We included randomised controlled trials (RCTs) that studied the efficacy of acupuncture treatment for oligo/anovulatory women with PCOS. We excluded quasi- or pseudo-RCTs.

Data collection and analysis: Two review authors independently selected the studies, extracted data and assessed risk of bias. We calculated risk ratios (RR), mean difference (MD), standardised mean difference (SMD) and 95% confidence intervals (CIs). Primary outcomes were live birth rate, multiple pregnancy rate and ovulation rate, and secondary outcomes were clinical pregnancy rate, restored regular menstruation period, miscarriage rate and adverse events. We assessed the quality of the evidence using GRADE methods.

Main results: We included eight RCTs with 1546 women. Five RCTs were included in our previous review and three new RCTs were added in this update of the review. They compared true acupuncture versus sham acupuncture (three RCTs), true acupuncture versus relaxation (one RCT), true acupuncture versus clomiphene (one RCT), low-frequency electroacupuncture versus physical exercise or no intervention (one RCT) and true acupuncture versus Diane-35 (two RCTs). Studies that compared true acupuncture versus Diane-35 did not measure fertility outcomes as they were focused on symptom control.Seven of the studies were at high risk of bias in at least one domain.For true acupuncture versus sham acupuncture, we could not exclude clinically relevant differences in live birth (RR 0.97, 95% CI 0.76 to 1.24; 1 RCT, 926 women; low-quality evidence); multiple pregnancy rate (RR 0.89, 95% CI 0.33 to 2.45; 1 RCT, 926 women; low-quality evidence); ovulation rate (SMD 0.02, 95% CI -0.15 to 0.19, I2 = 0%; 2 RCTs, 1010 women; low-quality evidence); clinical pregnancy rate (RR 1.03, 95% CI 0.82 to 1.29; I2 = 0%; 3 RCTs, 1117 women; low-quality evidence) and miscarriage rate (RR 1.10, 95% CI 0.77 to 1.56; 1 RCT, 926 women; low-quality evidence).Number of intermenstrual days may have improved in participants receiving true acupuncture compared to sham acupuncture (MD -312.09 days, 95% CI -344.59 to -279.59; 1 RCT, 141 women; low-quality evidence).True acupuncture probably worsens adverse events compared to sham acupuncture (RR 1.16, 95% CI 1.02 to 1.31; I2 = 0%; 3 RCTs, 1230 women; moderate-quality evidence).No studies reported data on live birth rate and multiple pregnancy rate for the other comparisons: physical exercise or no intervention, relaxation and clomiphene. Studies including Diane-35 did not measure fertility outcomes.We were uncertain whether acupuncture improved ovulation rate (measured by ultrasound three months post treatment) compared to relaxation (MD 0.35, 95% CI 0.14 to 0.56; 1 RCT, 28 women; very low-quality evidence) or Diane-35 (RR 1.45, 95% CI 0.87 to 2.42; 1 RCT, 58 women; very low-quality evidence).Overall evidence ranged from very low quality to moderate quality. The main limitations were failure to report important clinical outcomes and very serious imprecision.

Authors' conclusions: For true acupuncture versus sham acupuncture we cannot exclude clinically relevant differences in live birth rate, multiple pregnancy rate, ovulation rate, clinical pregnancy rate or miscarriage. Number of intermenstrual days may improve in participants receiving true acupuncture compared to sham acupuncture. True acupuncture probably worsens adverse events compared to sham acupuncture.No studies reported data on live birth rate and multiple pregnancy rate for the other comparisons: physical exercise or no intervention, relaxation and clomiphene. Studies including Diane-35 did not measure fertility outcomes as the women in these trials did not seek fertility.We are uncertain whether acupuncture improves ovulation rate (measured by ultrasound three months post treatment) compared to relaxation or Diane-35. The other comparisons did not report on this outcome.Adverse events were recorded in the acupuncture group for the comparisons physical exercise or no intervention, clomiphene and Diane-35. These included dizziness, nausea and subcutaneous haematoma. Evidence was very low quality with very wide CIs and very low event rates.There are only a limited number of RCTs in this area, limiting our ability to determine effectiveness of acupuncture for PCOS.

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Conflict of interest statement

The primary author of one included study is also the primary author (DL) of this review (Lim 2014). In order to minimise any potential risk of bias during the review process, two review authors (RN, GZ) independently extracted data using a piloted data extraction form. All studies were then assessed independently and any dispute was resolved by a third independent review author (HC).

Figures

1
1
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
3
3
Study flow diagram. PCOS: polycystic ovarian syndrome.
4
4
Forest plot of comparison: 1 True acupuncture versus sham acupuncture, outcome: 1.3 Ovulation rate.
5
5
Forest plot of comparison: 1 True acupuncture versus sham acupuncture, outcome: 1.4 Clinical pregnancy rate.
6
6
Forest plot of comparison: 1 True acupuncture versus sham acupuncture, outcome: 1.7 Adverse events.
1.1
1.1. Analysis
Comparison 1 True acupuncture versus sham acupuncture, Outcome 1 Live birth rate.
1.2
1.2. Analysis
Comparison 1 True acupuncture versus sham acupuncture, Outcome 2 Multiple pregnancy rate.
1.3
1.3. Analysis
Comparison 1 True acupuncture versus sham acupuncture, Outcome 3 Ovulation rate.
1.4
1.4. Analysis
Comparison 1 True acupuncture versus sham acupuncture, Outcome 4 Clinical pregnancy rate.
1.5
1.5. Analysis
Comparison 1 True acupuncture versus sham acupuncture, Outcome 5 Restored regular menstrual period.
1.6
1.6. Analysis
Comparison 1 True acupuncture versus sham acupuncture, Outcome 6 Miscarriage rate.
1.7
1.7. Analysis
Comparison 1 True acupuncture versus sham acupuncture, Outcome 7 Adverse events.
2.1
2.1. Analysis
Comparison 2 Low‐frequency electroacupuncture versus physical exercise or no intervention, Outcome 1 Restored regular menstrual period.
2.2
2.2. Analysis
Comparison 2 Low‐frequency electroacupuncture versus physical exercise or no intervention, Outcome 2 Adverse events.
3.1
3.1. Analysis
Comparison 3 True acupuncture versus relaxation, Outcome 1 Ovulation rate.
4.1
4.1. Analysis
Comparison 4 True acupuncture versus clomiphene, Outcome 1 Restored regular menstrual period.
4.2
4.2. Analysis
Comparison 4 True acupuncture versus clomiphene, Outcome 2 Adverse events.
5.1
5.1. Analysis
Comparison 5 True acupuncture versus Diane‐35, Outcome 1 Ovulation rate.
5.2
5.2. Analysis
Comparison 5 True acupuncture versus Diane‐35, Outcome 2 Adverse events.
See this image and copyright information in PMC

Update of

References

References to studies included in this review

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Fang 2016 {published data only}
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Hao 2015 {published data only}
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Huang 2016 {published data only}
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Jiang 2014 {published data only}
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Jiang 2015a {published data only}
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Jiang 2015b {published data only}
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Jin 2014 {published data only}
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Kuang 2013 {published data only}
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Li 2010 {published data only}
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Li 2011a {published data only}
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Li 2015 {published data only}
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Li 2017 {published data only}
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Liu 2012 {published data only}
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Liu 2017 {published data only}
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Peng 2017 {published data only}
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Qu 2012 {published data only}
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Rashidi 2013 {published data only}
    1. Rashidi BH, Tehrani ES, Hamedani NA, Pirzadeh L. Effects of acupuncture on the outcome of in vitro fertilisation and intracytoplasmic sperm injection in women with polycystic ovarian syndrome. Acupuncture in Medicine 2013;31(2):151‐6. - PubMed
Sun 2010 {published data only}
    1. Sun W, Cui W, Li J. Study of effect mechanism of electroacupuncture for polycystic ovarian syndrome in kidney deficiency pattern [电针干预对肾虚型PCOS患者影响机制的研究]. Chinese Journal of Birth Health & Heredity 2010;18(1):105‐7.
Wang 2013 {published data only}
    1. Wang H, Gu Z. Clinical observation of acupuncture plus medicine for polycystic ovarian syndrome with infertility [针药结合治疗多囊卵巢性不孕症临床观察]. Journal of Hubei University of Chinese Medicine 2013;15(6):57‐8.
Yang 2015 {published data only}
    1. Yang J, Xu J, Liu Y, Huang J. Clinical investigation on the effect of acupuncture‐induced artificial menstrual cycle on polycystic ovary syndrome related follicular dysplasia [针灸人工周期疗法治疗多囊卵巢综合征卵泡发育不良的临床研究]. Lishizhen Medicine and Materia Medica Research 2015;26(12):2954‐5.
Yang 2017 {published data only}
    1. Yang D, Zhao M, Tan J. Effect of polycystic ovary syndrome treated with the periodic therapy of acupuncture [针刺调周法治疗多囊卵巢综合征的临床疗效分析]. Zhongguo Zhenjiu 2017;37(8):825‐9. - PubMed
Yu 2013 {published data only}
    1. Yu L, Liao Y, Wu H, Zhao J, Wu L, Shi Y, et al. Effects of electroacupuncture and Chinese kidney‐nourishing medicine on polycystic ovary syndrome in obese patients. Journal of Traditional Chinese Medicine 2013;33(3):287‐93. - PubMed
Zhang 2013 {published data only}
    1. Zhang H. Acupuncture plus medicine for polycystic ovarian syndrome in 30 cases [针刺配合西药治疗多囊卵巢综合征30例]. China's Naturopathy 2013;21(11):60‐1.
Zhou 2016 {published data only}
    1. Zhou Y, Wu J, Lin W, Pi M, Chen P, Yang Z. The "regulating conception‐governor vessel" acupuncture method for infertility of polycystic ovarian syndrome [调任通督针刺法”治疗多囊卵巢综合征不孕症的临床疗效观察]. Zhongguo ZhenJiu 2016;36(12):1237‐40. - PubMed

References to ongoing studies

ChiCTR1800015738 {published data only}
    1. ChiCTR1800015738. Intervention of acupuncture based on metabonomics on key targets of PCOS dampness syndrome [基于代谢组学的针刺对PCOS痰湿证关键靶点的干预研究]. www.chictr.org.cn/showprojen.aspx?proj=26694 (first received 18 April 2018).
ChiCTR1800017304 {published data only}
    1. ChiCTR1800017304. A multicenter, randomized, controlled trial for comparing personalized acupuncture versus standardized acupuncture, versus letrozole, placebo in the treatment of anovulatory women with polycystic ovary syndrome [个性化针灸、标准化针灸、来曲唑和安慰剂对多囊卵巢综合症无排卵妇女活产率影响：多中心随机试验]. www.chictr.org.cn/showprojen.aspx?proj=28407 (first received 23 July 2018).
ChiCTR‐IOR‐15007358 {published data only}
    1. ChiCTR‐IOR‐15007358. A randomized controlled trial to evaluate the effectiveness of electroacupuncture for polycystic ovary syndrome [针刺治疗多囊卵巢综合症的随机对照研究]. www.chictr.org.cn/showproj.aspx?proj=12273 (first received 26 October 2015).
NCT02491333 {published data only}
    1. NCT02491333. The effect of acupuncture on insulin sensitivity of women with polycystic ovary syndrome and insulin resistance: a randomized controlled trial. clinicaltrials.gov/ct2/show/NCT02491333 (first received 8 July 2015).
NCT02647827 {published data only}
    1. NCT02647827. Acupuncture or metformin for insulin resistance in women with polycystic ovary syndrome: a randomized controlled trial. clinicaltrials.gov/ct2/show/NCT02647827 (first received 6 January 2016).
NCT02653911 {published data only}
    1. NCT02653911. Efficacy of acupuncture on menstrual frequency in women with polycystic ovary syndrome: protocol for a randomized, controlled trial. clinicaltrials.gov/ct2/show/NCT02653911 (first received 13 January 2016).

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