Fig. 7.1
These are some of the acupuncture points used in fertility. They are located in the head, lumbar area, thighs, and legs: Baihui DU20, REN3 Zhongji, E29 Guilai, Xuehai B10, B6 Sanyinjiao, E36 Zusanli, Hegu IG4
There is a growing body of research evaluating the effect of acupuncture administered during IVF, and specifically, on the day of embryo transfer [30, 31]. The first systematic review was published in 2008 by Manheimer et al. [31]. They found that acupuncture, as an adjunct to embryo transfer, was associated with a statistically and clinically significant increases in the pregnancy, ongoing pregnancy, and live birth rates [31]. Although these findings were encouraging, they were preliminary, and they need further placebo-controlled trials.
One of the possible pathophysiological mechanisms of acupuncture is the anesthesia-like effects. Acupuncture needles stimulate muscle afferents innervating ergoreceptors, which leads to increased β-endorphin concentration in the cerebrospinal fluid [32, 33]. The hypothalamic β-endorphinergic system has inhibitory effects on the vasomotor center, thereby reducing sympathetic activity. In addition to central sympathetic inhibition by the endorphin system, acupuncture stimulation of the sensory nerve fibers may inhibit the sympathetic outflow at the spinal level. By changing the concentration of central opioids, acupuncture may also regulate the function of the hypothalamic-pituitary-ovarian axis via the central sympathetic system [3]. Although in most clinical studies this mechanism is responsible for a higher pregnancy rate, it is still considered speculative.
Recently, several randomized controlled studies have shown a beneficial effect of acupuncture at the time of embryo transfer [30, 32, 34, 35]. Moreover, in a review from the Cochrane Collaboration [35], the pooled results of 6 trials including a total of 1,022 patients showed a significantly higher clinical pregnancy rate favoring the use of acupuncture on the day of embryo transfer. Several trials were heterogeneous and the results inconsistent. There are several possible explanations for the heterogeneity, the most common being the type of patients submitted in the trials and the different treatment protocols. Most of the reviews submitted women under 42 years old (mean = 32 ± 4) who were undergoing assisted reproductive technology (IVF/ICSI). They were blinded and divided into two groups, the control group and the other group that received acupuncture. The type of stimulation, number of transferred embryos, and diagnosis were similar [8, 29–37].
There still remains insufficient evidence to determine if acupuncture can enhance live birth rates when used as an adjunct to IVF treatment.
Transfer Position
In the first years of IVF, the position of the uterus dictated the position of the patient during transfer to bring the uterine fundus into a dependent level. The knee-chest position was used for an anteverted uterus and the dorsal lithotomy position for the retroverted uterus. At present, we place all patients in the dorsal lithotomy position regardless of the uterine position, as this does not appear to affect the pregnancy rate [38].
Bed Rest
Patients undergoing IVF were given a general recommendation for bed rest immediately after the embryo transfer. The rationale behind this recommendation came from the belief that decreased physical activity would encourage embryo retention within the uterine cavity after placement [39]. Mechanical expulsion of the transferred embryos is a possible cause for implantation failure and probably is the reason why most patients are asked to stay in bed for several hours following ET. However, the exact cause is not clearly understood [5].
Implantation in humans is not yet fully understood but is generally accepted to occur 4–7 days following fertilization. Bed rest for a few hours following ET is unlikely to affect implantation that will occur a few days later.
This approach, however, is not grounded on evidence-based trials. Sharif et al. [5] performed a retrospective study comparing 1,091 IVF cycles in patients who did and did not undergo bed rest and found no difference in the pregnancy rates [5].
Just a few studies were submitted until now, and no one demonstrated that bed rest has any influence on the IVF outcome. In those studies in which the patients chose not to have bed rest, they may have felt more confident and less stressed than those who chose bed rest after embryo transfer, and these positive feelings could have contributed to their chances of conceiving [40]. Patients’ own behavior can affect the treatment results and may lead to unnecessary concern and stress that lasts for weeks after the embryo transfer, as well as guilt feelings if pregnancy does not occur [40].
Practitioners should minimize the relevance of bed rest and focus on other ways of improving embryo transfer quality. The volume of air and media, as well as the density of media, have been shown to be important predictors of movement of the embryos within the uterine cavity and are not related to bed rest [41].
It is important that clinicians carefully explain these findings to their patients after ET and advise them to return to normal routine daily activities.
Intercourse
The conventional relationship between sexuality and conception is altered by infertility, with many couples reporting diminished sexual activity once they have been diagnosed as infertile. These difficulties are exacerbated by anxiety and the loss of privacy associated with infertility treatment and may be compounded by the fear that intercourse will dislodge the early implanting embryo [42].
The possible mechanisms that intercourse may affect embryo implantation could be ovarian torsion, infections, and uterine contraction.
Before Embryo Transfer
During the IVF process many women may experience tenderness and pain as the ovaries will become physically larger while they are being stimulated. There is a risk of ovarian torsion during this period. Ovarian torsion occurs when an ovary is twisted in such a way that the ovarian vein is distressed, resulting in severe abdominal pain, and is usually resolved through surgery. For this reason all torso-twisting activities and other abdominal exercises are not advised during this period.
After egg retrieval, it is advised to abstain from intercourse due to the risk of ovarian torsion and of infection. The wall of the cervix and uterus are more at risk from the retrieval procedure to upper reproductive tract infections, and the cervical mucus barrier to ascending infection is disrupted by the passage of the embryo transfer catheter [42].
After Embryo Transfer
There are different recommendations regarding intercourse during this period. Most practitioners recommend no sexual intercourse between transfer and first beta human chorionic gonadotropin (hCG) test. This is due to the belief that uterine myometrial activity is increased during intercourse, especially in the event of female orgasm. These contractions may interfere with implantation of the early embryo.
Until now, there is no scientific evidence which demonstrates that having sexual intercourse during this period affects the implantation rate.
Despite these events, there are a few clinical trials which indicate that intercourse may assist implantation. There have been animal studies in mice, which reveal that exposure to seminal plasma is particularly important for achieving normal embryo development and implantation. One of the mechanisms proposed for this is the immune-active compounds such as transforming growth factor beta (TGFβ) and prostaglandin E, both present in high concentrations in human semen. They may be responsible for the beneficial effect, but the mechanism is still unknown.
Stress and Emotional Factors
Fertility problems consist of both medical and emotional aspects. While the physical impact of the medical treatment is considerable, couples consider emotional aspects more stressful. For most couples, an unsuccessful IVF result means the end of further medical treatment possibilities. The main stress factor in infertility comprises various elements: the threat of treatment and possible childlessness, uncertainty and lack of control of the treatment outcome, and the loss of hopes of pregnancy and creating a family. Differentiating between anxiety and depression is important because they both require different psychosocial interventions [3, 43].
The role of psychological intervention in IVF results is very controversial. Zaig et al. [44] have recently demonstrated that transitory moods, such as anxiety and depression, have no predictive value on the outcome of IVF. Nevertheless, the incorporation of psychological interventions and even spirituality seems to improve the well-being of women during IVF cycles [45].
Domar et al. [46], in 1990, described a Mind/Body Program for Infertility. It is a 10-week group stress management program whose focus is on cognitive behavior therapy, relaxation training, negative health behavior modification, and social support components. Infertility patients with varied diagnoses and at different stages of treatment who participated in the Mind/Body Program for Infertility experienced significantly higher pregnancy rates than control subjects [47].
Attempts to comprehend whether psychological interventions have any beneficial effects over pregnancy rates in IVF/ET patients led to contradictory conclusions, indicating that there is probably no simple direct relationship [4, 48–52].
Nevertheless, psychological factors may be improved by intervention; with these in mind, we can be more aware of what kind of patients we are working with and we can recommend different types of counseling.
Prayer
The use of alternative or complementary medicine has been increasing in popularity; these approaches include the use of healing touch and prayer, with several reports suggesting a potential therapeutic benefit in a variety of disorders [53, 54]. In the last years, the use of intercessory prayer (IP) has been studied, and while preliminary experiments have been interpreted as suggesting a possible improvement in patients with heart disease and AIDS [55–57], a recent review of the literature does not indicate any conclusive benefit overall.
Petitionary or intercessory prayer (IP) is when the prayer participants request God’s intervention or assistance for the benefit of another individual, and directed IP is praying for a specific outcome for an individual or individuals (i.e., prayers for conception).
In relation with in vitro fertilization, there has been only one study with the intention of proving application of IP to the treatment of infertility. Kwang et al. [58] made a prospective, randomized, double-blind study in which the efficacy of IP was assessed in patients undergoing IVF-ET treatment. They included a total of 169 cases whose characteristics as age, duration of infertility, and number of prior attempts and IVF-ET were similar.
The study found that, during the treatment, both groups (those who received IP vs. no IP) had similar numbers of oocytes retrieved, numbers of oocytes fertilized, and pre-embryos transferred. The IP group, however, had a significantly higher pregnancy rate as compared to the controls (50 % vs. 26 %; P = 0.0013); these rates were not modified when they were adjusted by the variables, except in women undergoing ICSI and women under 30 years, in whom IP did not show any benefit. The adjusted OR for pregnancy rates (IP vs. no IP) was 3.3 (95 % CL, 1.6–6.6). Also, the implantation rate was significantly higher in the IP group (16.3 % vs. 8 %, P = 0.0005). The higher rate of pregnancies in the IP group was independent of the type of infertility [58].
These data suggest a benefit of IP on IVF-ET. However, it must be considered as preliminary because of the multiple biological factors and unknown variables inherent in the treatment process of IVF-ET.
Conclusions
Since the first successful birth from in vitro fertilization-embryo transfer in 1978, there have been numerous advances in IVF-ET. These advances have occurred in almost every aspect of the IVF process, but we still do not know why more than half of the patients do not get pregnant in each attempt. This opens the use of different medications, alternative medicines, spiritual and religious support, excessive bed rest, or lack of sexual activity that after 35 years have not yet been proven but, nevertheless, are widely used.
References
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