Stimulated by Erdoğan and Yardimci 2023.[1]
IUD – intrauterine device
key to acronyms
RCT – randomised controlled trial
VAS – visual analogue scale
AE – adverse event
SR – systematic review
IVF – invitro fertilisation
EiC – editor in chief
This is a small RCT from Turkey published in Archives of Gynaecology and Obstetrics (IF 2.6). I was not familiar with this journal, but it has been around since the end of the 19th century, February 1870 to be precise. It was an exclusively German language journal for the first 90 years but has been publishing in English for the last 40.
I picked this paper because of a conversation with a colleague (Dr Lauren Bull) at the BMAS London Teaching Clinic. She mentioned a case of a failed IUD insertion, which was subsequently successful after the addition of acupuncture. A few weeks later this paper popped up on PubMed.
It is the first RCT of acupuncture for pain control during IUD insertion (n=72). The methodology was a simple parallel arm study of bilateral LI4 acupuncture versus no acupuncture. Needles were stimulated manually and left in place for 15 minutes. They were removed before IUD insertion. The outcome was VAS pain at 3 minutes and 10 minutes post insertion.
The 3-minute outcome was to cover the cervical component of the procedural pain, including removal of the cervical clamp (tenaculum), and the 10-minute outcome was aiming to assess the delayed onset pain from the fundus of the uterus.
The doctor performing the insertion was blind to the intervention, but clearly the patients were not since there was no sham.
The trial will be criticised for a lack of sham but why do you need a sham when the intervention is cheap and virtually risk free? Placebo or sham allows us to be sure that our intervention is likely to do more good than harm. So, if the risk of harm is negligible, a no treatment control is acceptable, particularly if there are no inactive shams available, or if the use of a sham device reduces the effect of real acupuncture by limiting the technique.
Needling at LI4 is not entirely without risk,[2] but on balance it is a very safe procedure, and in this trial, there were no needle related AEs.
Mean VAS pain at 3 minutes was ~4 in the no acupuncture group and ~2 in the acupuncture group, and at 10 minutes, 1.6 and 0.5 respectively. Linear regression analysis found that acupuncture and time from the last delivery were both significant predictors for lower VAS pain at 3 minutes, but only acupuncture predicted lower VAS pain at 10 minutes.
It is hard to see why this could not be adopted immediately, but of course that will not happen in overly bureaucratic health services.
In the same week and the same journal, but on the other side of the fertility scale, we have the first SR of acupuncture in IVF for several years.[3] There was a time when SRs of acupuncture in IVF were coming thick and fast. Over a seven-year period from 2008 to 2014, we saw 12 of them. When our EiC, David Coggin-Carr, summarised them in an editorial,[4] he listed a total of 33 papers. So, it was disappointing to see only 25 papers listed in this SR, and none of the ones with negative results. They listed 11 papers published since David’s editorial, so they only included 14 out of his 33.
This SR was positive for acupuncture, but since so many papers were inexplicably left out, including the relatively large and high profile negative trials,[5–7] it is not really worth spending more time on.
References
1 Erdoğan P, Yardımcı H. Analgesic effects of LI4 acupuncture during intrauterine device insertion: a randomized controlled clinical trial. Arch Gynecol Obstet Published Online First: 19 July 2023. doi:10.1007/s00404-023-07106-5
2 Cummings M, Klonowska M, Ferreira SH. Arterial injury at LI4. Acupunct Med 2018;36:343–4. doi:10.1136/acupmed-2018-011641
3 Xu M, Zhu M, Zheng C. Effects of acupuncture on pregnancy outcomes in women undergoing in vitro fertilization: an updated systematic review and meta-analysis. Arch Gynecol Obstet Published Online First: 12 July 2023. doi:10.1007/s00404-023-07142-1
4 Carr D. Somatosensory stimulation and assisted reproduction. Acupunct Med 2015;33:2–6. doi:10.1136/acupmed-2014-010739
5 So EWS, Ng EHY, Wong YY, et al. A randomized double blind comparison of real and placebo acupuncture in IVF treatment. Hum Reprod 2009;24:341–8. doi:10.1093/humrep/den380
6 So EWS, Ng EHY, Wong YY, et al. Acupuncture for frozen-thawed embryo transfer cycles: a double-blind randomized controlled trial. Reprod Biomed Online 2010;20:814–21. doi:10.1016/j.rbmo.2010.02.024
7 Smith CA, de Lacey S, Chapman M, et al. Effect of Acupuncture vs Sham Acupuncture on Live Births Among Women Undergoing In Vitro Fertilization: A Randomized Clinical Trial. JAMA 2018;319:1990–8. doi:10.1001/jama.2018.5336
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