A new study shows that acupuncture is no more effective than sham acupuncture for women undergoing IVF. That means it doesn't work. Sort of.
Today, we’re talking about acupuncture and its role in in vitro fertilization, as laid out in this article appearing in the Journal of the American Medical Association.
Is acupuncture pseudoscientific woo, or a valuable weapon in our therapeutic armamentarium?
As always, we should start with biologic plausibility. Is it biologically plausible that acupuncture should increase the live birth rate in women undergoing IVF? Well, it depends what you mean by acupuncture. If, by acupuncture, you mean the insertion of needles in very specific locations to alter the flow of an immeasurable energy force within the body, then – no there is no biologic plausibility there.
But acupuncture may not be totally without physiologic effect. Perhaps the local stimulation of nerve endings can release endorphins or promote blood flow (though these claims are actually a bit controversial). But of course, if that’s the case sham acupuncture (where the needles are placed randomly) should work just as well as “real” acupuncture for IVF.
And indeed, that is what was found.
848 women undergoing IVF across multiple sites were randomized to acupuncture (with needles specifically placed to increase the chances of successful birth) or sham acupuncture (non-invasive needles placed randomly).
18.3% of women in the acupuncture group had a live birth compared to 17.8% in the sham acupuncture group, a difference that was not statistically significant.
The use of a rigorous sham control here demonstrates what we know deep down – there is nothing magical about acupuncture.
This is not to say it is without value. As a clinical researcher, when I look at an acupuncture study the first thing I think of is “cointervention bias”. Acupuncture is so much more than the sticking of needles into specific locations. It’s a quiet room, soft music, a compassionate therapist, and human touch.
These are all things that might be really beneficial.
But the JAMA study brings up one new wrinkle. The “real” acupuncture group had more adverse events than the sham group, mostly bruising and pain at the needle sites. But in addition, the real acupuncture group had a 22.8% miscarriage rate, compared to an 11.6% in the sham group.
My own calculation suggests this is a statistically significant difference at a p-value of less than p=0.05* which should certainly concern women considering acupuncture during IVF. But to be fair, I do not have access to the primary data or the full statistical model that was used to generate the p-value of 0.054 that appears in the paper.
But regardless - given that sham acupuncture was just as good, shouldn’t we just abandon insertive acupuncture altogether and focus more on the acupuncture experience – the quiet room, the soothing voice of the practitioner, human touch. After all, the evidence suggests that that’s really the point.
*CORRECTION (5/17/18): The original version of this commentary reported my p-value calculation of less than p=0.01 for the outcome of miscarriage. This was an error. I had assumed that the reported percentage of miscarriage (22.8 vs. 11.6%) was in the entire cohort, but further review revealed that these were the percent of miscarriage among women who had a clinical pregnancy. A chi-square test gives a p-value of 0.045 in using this denominator. If the total treatment group is used, the chi-square p-value is 0.02. I have reached out to the author to determine the statistical test used for this data point and will update this further, but a comment correctly notes that a Fishers exact test using the "clinical pregnancy" denominator equals 0.055. We should remember that p-values are a spectrum, and there is no "magic" about a p-value of 0.05. My overall conclusion that in the absence of evidence for efficacy, and weak evidence for harm, insertive acupuncture for IVF is difficult to justify.