Intervention Protocol

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Acupuncture for female subfertility

  1. Xiaoshu Zhu1,*,
  2. Chi Eung Danforn Lim2,
  3. Helen E Nagels3

Editorial Group: Cochrane Menstrual Disorders and Subfertility Group

Published Online: 28 MAR 2013

DOI: 10.1002/14651858.CD010462

How to Cite

Zhu X, Lim CED, Nagels HE. Acupuncture for female subfertility (Protocol). Cochrane Database of Systematic Reviews 2013, Issue 3. Art. No.: CD010462. DOI: 10.1002/14651858.CD010462.

Author Information

  1. 1

    School of Health and Science, University of Western Sydney, Center for Complementary Medicine Research, Sydney, New South Wales, Australia

  2. 2

    University of New South Wales, South Western Sydney Clinical School, Faculty of Medicine, Blakehurst, New South Wales, Australia

  3. 3

    University of Auckland, Obstetrics and Gynaecology, Auckland, New Zealand

*Xiaoshu Zhu, Center for Complementary Medicine Research, School of Health and Science, University of Western Sydney, Building 24, Campbelltown Campus, Locked Bag 1797, Penrith South DC, Sydney, New South Wales, 2751, Australia. x.zhu@uws.edu.au. mszhuxiaoshu@yahoo.com.

Publication History

  1. Publication Status: New
  2. Published Online: 28 MAR 2013

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Background

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Acknowledgements
  6. Appendices
  7. Contributions of authors
  8. Declarations of interest
  9. Sources of support

       

 

Description of the condition

The definition of subfertility remains a subject of debate (Gnoth 2005) and confusion between the definition of infertility and subfertility often occurs. Evers (Evers 2002) and He (He 2004) have stated that infertility is the absolute inability to conceive, whilst subfertility is not described as irreversible but rather as any form or grade of diminished ability to conceive over a prolonged time (usually at least six menstrual cycles) (Gnoth 2005). The International Committee for Monitoring Assisted Reproductive Technology (ICMART) and the World Health Organization (WHO) in their revised terminology document state that the clinical definition of infertility is "a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse" (Zegers-Hochschild 2009). Many women with clinical subfertility will eventually conceive spontaneously; for example, after 12 unsuccessful cycles the live birth rate among untreated couples with subfertility will reach nearly 50% in the following 36 months, which is equivalent to slightly reduced fertility. However, approximately 5% of these couples have little chance of falling spontaneously pregnant in the next 48 months and these are defined as infertile or sterile (Gnoth 2005). Fertility, subfertility, infertility and sterility are therefore not dichotomous (Evers 2002; Gnoth 2005).

Subfertility without any prior pregnancy is termed 'primary subfertility', whilst 'secondary subfertility' is when couples are unable to conceive the number of children desired (He 2004). There is a strong trend towards increased subfertility as women increasingly delay having children until a time when their natural capacity to conceive is in decline (Boivin 2007; Evers 2002).

The main factors which contribute to subfertility are ovulation dysfunction, tuboperitoneal diseases and male factors, such as azoospermia or oligospermia (absent or low sperm count); subfertility may also be unexplained (Evers 2002). Endometrial and uterine factors, as well as advancing female age, probably also contribute to impaired fertility (Adamson 2003).

The diagnosis of subfertility varies, depending upon the cause. With respect to unexplained subfertility, it is a diagnosis of exclusion of abnormalities through standard investigations of both members of a couple (Athaullah 2002). There are also several prediction models which have been developed to make accurate predictions of a couple's chance of conceiving naturally (Van Geloven 2012; Verhoeve 2011).

Treatment such as assisted reproductive technologies (ART), including intra-uterine insemination (IUI), with or without controlled ovarian hyperstimulation (COH) and in vitro fertilisation (IVF), are often recommended upon a diagnosis of subfertility. Treatments include COH with IUI for ovulation dysfunction and unexplained subfertility; surgery for pelvic adhesions, endometriosis and myomas; and IVF for severe tubal factors or failure to conceive with standard infertility treatment (Adamson 2003; Evers 2002). However, determining the effectiveness of treatment is difficult given that few well-designed and analysed studies have been carried out in reproductive medicine (Adamson 2003).      

The aim of this systematic review is to investigate the effectiveness and safety of acupuncture for the management of subfertility based on the results of randomised controlled trials (RCTs). Acupuncture trials with a focus on primary clinical outcomes other than fertility should be investigated in separate systematic reviews.   

 

Description of the intervention

Acupuncture, as one of the main forms of traditional Chinese medicine (TCM), has been practised within the Chinese healthcare system for thousands of years (Qiu 1993). Since the late 20th century, the demand for acupuncture has been growing steadily in many Western nations (Hamilton 2008; Harkin 2007; Zhu 2009; Qiu 1993; Schmincke 2008). In 2006, an interview survey conducted by the National Institutes of Health in the United States indicated that 1.1% of their population (representing 2.13 million Americans) reported recent use of acupuncture (Burke 2006). Subfertility is one of the common problems which cause people to seek acupuncture treatment (Ng 2008).  

There are several different forms of acupuncture including body acupuncture, electroacupuncture, auricular acupuncture and scalp acupuncture (Qiu 1993).

  • Body acupuncture is defined as needling acupuncture points on the human body along the traditional meridians and excludes cranial and ear points (Lan 1997).
  • Electroacupuncture is the stimulation of acupuncture points by electrical current (Qiu 1993).
  • Auricular acupuncture is a micro system within TCM and involves stimulation of acupuncture points in the ear (Qiu 1993).
  • Scalp acupuncture is the parallel insertion of needles along the scalp for treating neurological conditions (Qiu 1993).

Although subfertility was not recorded explicitly in the classical texts as a defined entity, the word subfertility is often used interchangeably with infertility (Xia 1994). Contemporary TCM researchers acknowledge the two types of impaired fertility: the absolute inability to conceive and the relative diminished ability to conceive, which is the focus of TCM practice (Song 2008).

According to the TCM philosophical framework, there is a natural pattern of vital energy (Qi) throughout the body; a disruption in this flow of energy indicates disease (Maciocia 1998). The key pathology of subfertility is impeded function of the kidneys (the kidneys are the main organ in charge of reproduction within the TCM framework). Subfertility also results from impairment or obstruction of the flow of energy in the Chong and Ren meridians, which are associated with the uterus and ovaries. It is believed that a constitutional deficiency is the underlying pathology. The principle of the application of acupuncture is to strengthen the impaired organ and channels and unblock the obstruction in the related channels (Luo 1986; Xia 1994).  

 

How the intervention might work

The mechanism of action of acupuncture in the treatment of female subfertility remains largely unclear. However, emerging literature suggests that acupuncture mediates and alters specific hormone levels. Modern researchers have revealed that the effect of acupuncture in relation to fertility might be mediated through central neurotransmitters including ß-endorphin and serotonin, resulting in the release of gonadotropin-releasing hormone (GnRH) and thereby influencing pituitary gonadotropin secretion, ovarian follicular growth and finally ovulation (Chang 2002; Petti 1998). Studies of auricular and body acupuncture have also indicated that ovulation induction might occur through the mediation of the hypothalamic-pituitary ovarian axis (Cai 1997; Chen 2007; Xiang 2002).

In addition, Westergaard and co-workers conducted a randomised trial and concluded that acupuncture significantly improves the reproductive outcome of IVF/intracytoplasmic sperm injection (ICSI) on the day of embryo transfer compared with no acupuncture. They therefore postulated that acupuncture might have a general sympathoinhibitory effect, which in turn increases uterine and ovarian blood flow (Westergaard 2006). Acupuncture appears to have a favourable safety profile (Highfield 2006).

 

Why it is important to do this review

Subfertility is a prevalent problem, despite significant advances in the techniques available in the field of reproductive medicine. And there are still opportunities to explore the optimisation of treatment modalities. Treatments should have proven effectiveness with low risk (Gnoth 2005). At present, reproductive treatment leads to large financial, social and psychological burdens for couples and the community (Myers 2008), with increased risks of multiple pregnancy, miscarriages and ovarian cancer (Bensdorp 2007; Hughes 2010).

Acupuncture has been used recently in the management of subfertility (Ng 2008). Investigations of the use of acupuncture in assisted reproduction are increasing, in particular in the industrial developed countries. The main attractions for patients and health professionals of using acupuncture for fertility problems are that in general it is inexpensive and relatively painless, with no known adverse side effects if performed by qualified personnel. While public interest in the use of acupuncture for the improvement of fertility arises from time to time, there is demand for evidence of proven effectiveness (Domar 2006). A systematic review of the use of acupuncture for female subfertility to determine effectiveness and safety will address these needs and demands.     

 

Objectives

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Acknowledgements
  6. Appendices
  7. Contributions of authors
  8. Declarations of interest
  9. Sources of support

To evaluate the clinical effectiveness and safety of acupuncture for female subfertility.

 

Methods

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Acknowledgements
  6. Appendices
  7. Contributions of authors
  8. Declarations of interest
  9. Sources of support
 

Criteria for considering studies for this review

 

Types of studies

Inclusion criteria:

  • Truly randomised controlled trials including double-blinded, single-blinded and cluster-randomised trials published in any language.

Exclusion criteria:

  • Quasi-randomised trials.
  • Cross-over trials if pre-cross-over data cannot be obtained.

 

Types of participants

Inclusion criteria:

Trials that include women of childbearing age of any ethnic origin, who have been unable to conceive for at least 12 months (including primary and secondary subfertility), with or without explained reasons. Women undergoing assisted reproductive technology (ART) and surgery will also be included if acupuncture is incorporated.

We will divide the subfertility studies into the following sub-categories:

  • Ovulation dysfunction (e.g. polycystic ovarian syndrome (PCOS), age-related ovulation)
  • Tubal disease (e.g. hydrosalpinx)
  • Endometriosis factor (e.g. endometriosis and associated abnormalities of peritoneum) 
  • Uterine abnormalities (e.g. intrauterine adhesions, polyps, fibroids) 
  • Unexplained subfertility

Exclusion criteria:

  • Trials that include male factor as the primary reason for subfertility (such as sperm dysfunction: azoospermia or oligospermia (absent or low sperm count))
  • Trials that include PCOS, tubal diseases and endometriosis and other associated diseases with no fertility outcome, as these are the subject of other Cochrane reviews

 

Types of interventions

Types of interventions will include body acupuncture with needle insertion at traditional acupuncture points or insertion at non-traditional points, also called 'Ashi' or tender areas; scalp or auricular acupuncture; and electroacupuncture.

The source of stimulation can be the hand, moxibustion such as a warming needle or electrical stimulation.

We will exclude acupuncture studies that involved non-insertive techniques, laser acupuncture, acupressure, point injection, bloodletting tap pricking or cupping on pricked superficial blood vessels.

We will exclude trials only comparing different acupuncture treatments.

We will exclude Japanese-style acupuncture since the needle technique and diagnostic evaluation are quite distinct in Japanese and Chinese-style acupuncture.

The control intervention can be placebo, also called sham acupuncture (with the use of a non-penetrating needle) (Streitberger 1998), or use of non-traditional acupoints that are not tender to touch and are located in the vicinity of traditional acupoints (Zhang 2010), herbal medicine, conventional biomedical treatment or no treatment at all. 

Specific interventions considered will be as follows.

 

Acupuncture without additional stimulation, except hand manipulation

  • Acupuncture (body, scalp, auricular) versus placebo or sham acupuncture
  • Acupuncture (body, scalp, auricular) versus no treatment
  • Acupuncture (body, scalp, auricular) plus conventional therapies (e.g. IUI, surgical intervention) versus conventional therapies (e.g. IUI, surgical intervention)

 

Acupuncture with additional stimulation

  • Acupuncture (body, scalp, auricular) with stimulation (electronic recurrence, moxa) versus placebo or sham acupuncture with stimulation (electronic recurrence, moxa)
  • Acupuncture (body, scalp, auricular) with stimulation (electronic recurrence, moxa) versus no treatment
  • Acupuncture (body, scalp, auricular) with stimulation (hand, electronic recurrence, moxa) plus conventional therapies (e.g. IUI, surgical intervention) versus conventional therapies (e.g. IUI, surgical intervention)

 

Types of outcome measures

 

Primary outcomes

  • Live birth rate per woman (live birth is defined as the delivery of a live fetus after 20 completed weeks of gestational age)

 

Secondary outcomes

  • Clinical pregnancy rate per woman (pregnancy is established with a hCG test in blood or urine and confirmed by ultrasound) 
  • Ongoing pregnancy rate per woman
  • Frequency of ovulation (for women with ovulation disturbances measured by mid-luteal progesterone in urine or serum)
  • Cost-effectiveness
  • Psychosocial factors
  • Quality of life
  • Adverse events arising from acupuncture:

    • The incidence of ovarian hyperstimulation syndrome per women (OHSS) 
    • Multiple pregnancy rate per woman
    • Miscarriage rate per woman
    • Ectopic pregnancy rate per woman 
    • Still birth rate per woman
    • Other adverse effects (such as headache)

 

Search methods for identification of studies

We will search for all published and unpublished RCTs of acupuncture for female subfertility, without language restriction and in consultation with the Cochrane Menstrual Disorders and Subfertility Group (MDSG) Trials Search Co-ordinator.

 

Electronic searches

We will adopt the Cochrane MDSG search strategy in consultation with the Trials Search Co-ordinator; search strings are shown in Appendix 1. We will obtain reports which describe (or might describe) randomised controlled trials of acupuncture in the treatment of subfertility using the following search strategy.

  • We will search the Cochrane MDSG Specialised Register of controlled trials for any trials within the scope of the review using the title, abstract or keyword sections.
  • We will search the following electronic databases in English from their inception to present: MEDLINE, EMBASE, CINAHL, AMED, CENTRAL and PsycINFO.

We will combine the MEDLINE search with the Cochrane highly sensitive search strategy for identifying randomised trials, which appears in the searching chapter of the Cochrane Handbook of Systematic Reviews of Interventions (Higgins 2011). We will combine the EMBASE search with the trial filters developed by the Scottish Intercollegiate Guidelines Network (SIGN) (http://www.sign.ac.uk/methodology/filters.html#random).

Other electronic sources of trials will include the following.

 

Searching other resources

We will handsearch the reference lists of articles retrieved by the search and make personal contact with experts in the field to obtain any additional relevant data.

We will handsearch any relevant journals and conference abstracts that are not covered in the MDSG register in liaison with the Trials Search Co-ordinator.

 

Data collection and analysis

We will conduct data collection and analysis in accordance with the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011).

 

Selection of studies

Two review authors (XS and DL) will undertake the study selection. XS will screen the titles and abstracts of articles found in the search and discard studies that are clearly ineligible, but will aim to be overly inclusive rather than risk losing relevant studies. XS will also obtain copies of the full-text articles and will make copies for DL in which details of the authors and institutions have been struck out and the results sections removed. Both review authors will independently assess whether the studies meet the inclusion criteria, with disagreements to be resolved by discussion. We will seek further information from the authors where papers contain insufficient information to make a decision about eligibility. We will document the selection process with a 'PRISMA' flow chart.

 

Data extraction and management

The two review authors (XZ and DL) will perform all assessments on the quality of trials and perform data extraction independently. We will extract data onto a pre-developed data extraction sheet to assess study characteristics including the location of the study, methods of the study (as per quality assessment checklist), the participants (age range, eligibility criteria), the nature of the interventions and data relating to the outcomes specified above. Any discrepancies will be resolved by a third review author (HN).

We will seek additional information on the trial methodology or actual original trial data from the principal author of those trials which appear to meet the eligibility criteria.

 

Assessment of risk of bias in included studies

We will assess the included studies for risk of bias using the Cochrane 'Risk of bias' assessment tool (Higgins 2011) for the following domains: selection bias (random sequence generation and allocation concealment); performance bias (blinding of participants and personnel); detection bias (blinding of outcome assessment); attrition bias (completeness of outcome data); reporting bias (selective reporting) and other potential sources of bias. Two authors (XZ and DL) will assess these six domains, with any disagreements resolved by consensus or by discussion with a third author (HN). We will grade each domain as at low, unclear or high risk of bias. We will fully describe all judgements and present the conclusions in the 'Risk of bias' tables, which we will incorporate into the interpretation of review findings by means of sensitivity analyses. We will provide a context for discussing the reliability of the results.

We will take care to search for within-trial selective reporting, such as trials failing to report obvious outcomes (including adverse events), or reporting them in insufficient detail to allow inclusion. We will seek published protocols and compare the outcomes between the protocol and the final published study.

Where identified studies fail to report the primary outcome of live birth, but do report interim outcomes such as pregnancy, we will undertake informal assessment as to whether the interim values (e.g. pregnancy rates) are similar to those reported in studies that also report live birth.

 

Measures of treatment effect

We will perform statistical analysis in accordance with the guidelines developed by The Cochrane Collaboration (Higgins 2011).

For binary outcomes, we will express the results for each study as odds ratios with 95% confidence intervals and combine them for meta-analysis using the Peto method.

For continuous outcome data, we will express the results for each study as the difference in means with 95% confidence intervals and combine them for meta-analysis using the mean difference (MD). It is anticipated that different scales may be used to report the same outcomes (e.g. hot flushes); in this case we will use the standardised mean difference.

We will treat ordinal data (e.g. quality of life scores) as continuous data. We will present 95% confidence intervals for all outcomes.

 

Unit of analysis issues

We will analyse dichotomous outcomes per woman randomised (e.g. the number of women with an adverse effect/total number of women randomised). When data are presented in continuous form we will treat data so that participants from individual trials will be included only once in each comparison. Only first-phase data from cross-over trials will be included.

 

Dealing with missing data

We will analyse data on an intention-to-treat basis where possible. We will contact primary study authors by phone or email to obtain any missing patient data. We will record the rate of contact. We will note discrepancies between the number of patients enrolled and number of patients in whom outcomes were reported in the 'Characteristics of included studies' table. We may impute individual values for the primary outcomes only. We will assume live births not to have occurred in participants without a reported outcome. For other outcomes, we will only analyse the available data. We will subject any imputation undertaken to sensitivity analysis.

 

Assessment of heterogeneity

We intend to use the concealment of allocation grading in the investigation of any heterogeneity and in sensitivity analyses. Other aspects of study quality include the extent of blinding (if appropriate), the extent of losses to follow-up, non-compliance, whether the outcome assessment was standardised and whether an intention-to-treat analysis was undertaken.

We will identify heterogeneity by visual inspection of the forest plots and by using a standard Chi2 test with an alpha significance level of 0.1. We will specifically examine heterogeneity (variation) between the results of different studies using the I2 statistic. An I2 value ranging from 50% to 90% may indicate substantial heterogeneity (Higgins 2011). We intend to perform pre-determined sub-analyses in order to explore the cause(s) of heterogeneity.

 

Assessment of reporting biases

In view of the difficulty in detecting and correcting for publication bias and other reporting biases, we will aim to minimise their potential impact by ensuring a comprehensive search for eligible studies and by being alert for duplication of data. If there are 10 or more studies in an analysis, we will use a funnel plot to explore the possibility of small study effects (a tendency for estimates of the intervention effect to be more beneficial in smaller studies).

 

Data synthesis

If the studies are sufficiently similar, we will combine the data from primary studies using a fixed-effect model in the following comparisons:

  1. acupuncture versus no treatment;
  2. acupuncture versus placebo;
  3. acupuncture versus conventional treatment.

We will display graphically an increase or decrease in the odds of a particular outcome, which may be beneficial or detrimental, in the meta-analyses. We will display an increase in the odds of an outcome to the right of the centre line and a decrease in the odds of an outcome to the left of the centre line.

In the event of substantial clinical, methodological or statistical heterogeneity, we will not combine study results by means of meta-analysis, but instead will summarise them in narrative form.

 

Subgroup analysis and investigation of heterogeneity

Where data are available, we will conduct subgroup analyses to determine the evidence for acupuncture in different subsets of subfertility and for different outcomes, according to the different types of acupuncture, in order to investigate heterogeneous results.

 

Sensitivity analysis

We will undertake sensitivity analysis to examine the stability of the results in relation to a number of factors relating to the way a study was done. We will repeat the analysis as follows:

  1. excluding studies based on the 'Risk of bias' assessment, e.g. first low risk of bias for allocation and then high or unclear risk of bias for allocation (in other words excluding studies without adequate safeguards for allocation concealment) (quasi-randomised studies will be excluded);
  2. excluding studies of poor overall methodological quality; we will consider the following aspects of quality for this sensitivity analysis: inadequate blinding, no stated method of diagnosis, incomparable groups (either because they have different baseline characteristics or they do not have identical care programmes), no intention-to-treat analysis;
  3. using a random-effect model.

 

Overall quality of the body of evidence: 'Summary of findings' table

We will generate a 'Summary of findings' table using GRADEpro software. This table will evaluate the overall quality of the body of evidence for the main review outcomes, using GRADE criteria (study limitations (i.e. risk of bias), consistency of effect, imprecision, indirectness and publication bias). We will justify, document and incorporate into our reporting of results for each outcome our judgements about evidence quality (high, moderate or low).

 

Acknowledgements

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Acknowledgements
  6. Appendices
  7. Contributions of authors
  8. Declarations of interest
  9. Sources of support

Marian Showell, Cochrane Menstrual Disorders and Subfertility Group (MDSG) Trials Search Co-ordinator.

Ms Guining Jiang, University of Western Sydney, Australia.

 

Appendices

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Acknowledgements
  6. Appendices
  7. Contributions of authors
  8. Declarations of interest
  9. Sources of support
 

Appendix 1. Search strings for English databases

Keywords CONTAINS "acupoint" or "acupressure" or "acupressure-acupuncture therapy" or "acupuncture" or "electro-acupuncture" or "electroacupuncture" or "moxibustion" or Title CONTAINS"acupoint" or "acupressure-acupuncture therapy" or "acupuncture" or "electro-acupuncture" or "electroacupuncture" or "moxibustion"

AND

Keywords CONTAINS "subfertility" or "subfertility-Female" or "female factor" or "infertility" or "infertility management" or "in vitro fertilisation" or "in vitro fertilization" or "IVF" or "ICSI" or "IUI" or "Intrauterine Insemination" or "ART" or "assisted conception" or "assisted reproduction" or "assisted reproduction techniques" or "insemination, intrauterine " or "insemination"  or "*Embryo Transfer" or "fertility" or Title CONTAINS "subfertility" or "subfertility-Female" or "female factor" or "infertility" or "infertility management" or "in vitro fertilisation" or "in vitro fertilization" or "IVF" or "ICSI" or "IUI" or "Intrauterine Insemination" or "ART" or "assisted conception" or "assisted reproduction" or "assisted reproduction techniques" or "insemination, intrauterine " or "insemination"  or "*Embryo Transfer"  or "fertility"

 

Appendix 2. Search strings for Chinese databases

Search term in Chinese:

 “针灸” 或“针灸治疗” 或 “针刺治疗” 或 “针灸疗法” 或 “针灸临床” 或“电针” 或“电针治疗” 或 “中西医结合治疗” 或“中西医结合疗法,

并且 “难孕” 或"不孕”或“难妊娠” 或“不孕妇女” 或“不育症,” 或“不明原因” 并且“怀孕困难” 并且“ 女性” 或“妇女”.

Search term in Chinese (Pingyin):

“Zhen Jiu” or“Zhen Jiu Zhi Liao” or “Zhen Ci Zhi Liao” or “Zhen Jiu Liao Fa” or “Zhen Jiu Lin Chuang” or“Dian Zhen” or“Dian Zhen Zhi Liao” or “Zhong Xi Yi Jie He Zhi Liao” or “Zhong Xi Yi Jie He Liao Fa”,

And “Nan Yun” or"Bu Yun” or “Nan Ren Shen” or“Bu Yun Fu Nv” or“Bu yu Zheng”, or“Bu Ming Yuan Yin” and “Huai Yun Kun Nan”and “ Nv Xing” or “Fu Nv”.

 

Appendix 3. CENTRAL search strategy (The Cochrane Library)

1 exp Acupressure/
2 exp acupuncture therapy/ or exp acupuncture analgesia/ or exp acupuncture, ear/ or exp electroacupuncture/ or exp meridians/ or exp moxibustion/
3 exp Acupuncture/ or exp Acupuncture Points/
4 Acupuncture.tw.
5 electroacupuncture.tw.
6 meridian$.tw.
7 moxi$.tw.
8 Acup$ Point$.tw.
9 Acupressure.tw.
10 electro acupuncture.tw.
11 needling.tw.
12 Shu.tw.
13 (shiatsu or tui na).tw.
14 or/1-13
15 exp Infertility, Female/
16 (female$ adj3 subfertility).tw.
17 (female$ adj3 infertility).tw.
18 (women adj3 subfertility).tw.
19 (women adj3 infertility).tw.
20 female$ fertility.tw.
21 (women adj1 fertility).tw.
22 (in vitro fertilisation or intracytoplasmic sperm injection$).tw.
23 intrauterine insemination$.tw.
24 (ivf or icsi or iui).tw.
25 in vitro fertilization.tw.
26 ART.tw.
27 Artificial reproduc$ technique$.tw.
28 exp reproductive techniques, assisted/ or exp embryo transfer/ or exp fertilization in vitro/ or exp sperm injections, intracytoplasmic/ or exp insemination, artificial/ or exp zygote intrafallopian transfer/
29 or/15-28
30 14 and 29

 

Appendix 4. MEDLINE search strategy (Ovid)

1 exp Acupressure/
2 exp acupuncture therapy/ or exp acupuncture analgesia/ or exp acupuncture, ear/ or exp electroacupuncture/ or exp meridians/ or exp moxibustion/
3 exp Acupuncture/ or exp Acupuncture Points/
4 Acupuncture.tw.
5 electroacupuncture.tw.
6 meridian$.tw.
7 moxi$.tw.
8 Acup$ Point$.tw.
9 Acupressure.tw.
10 electro acupuncture.tw.
11 needling.tw.
12 Shu.tw.
13 (shiatsu or tui na).tw.
14 or/1-13
15 exp Infertility, Female/
16 (female$ adj3 subfertility).tw.
17 (female$ adj3 infertility).tw.
18 (women adj3 subfertility).tw.
19 (women adj3 infertility).tw.
20 female$ fertility.tw.
21 (women adj1 fertility).tw.
22 (in vitro fertilisation or intracytoplasmic sperm injection$).tw.
23 intrauterine insemination$.tw.
24 (ivf or icsi or iui).tw.
25 in vitro fertilization.tw.
26 ART.tw.
27 Artificial reproduc$ technique$.tw.
28 exp reproductive techniques, assisted/ or exp embryo transfer/ or exp fertilization in vitro/ or exp sperm injections, intracytoplasmic/ or exp insemination, artificial/ or exp zygote intrafallopian transfer/
29 or/15-28
30 14 and 29
31 randomized controlled trial.pt.
32 controlled clinical trial.pt.
33 randomized.ab.
34 placebo.tw.
35 clinical trials as topic.sh.
36 randomly.ab.
37 trial.ti.
38 (crossover or cross-over or cross over).tw.
39 or/31-38
40 (animals not (humans and animals)).sh.
41 39 not 40
42 30 and 41

 

Appendix 5. EMBASE search strategy (Ovid)

1 exp acupuncture/ or exp therapy/ or exp acupressure/ or exp catgut embedding/ or exp electroacupuncture/
2 Acupuncture.tw.
3 electroacupuncture.tw.
4 meridian$.tw.
5 moxi$.tw.
6 Acup$ Point$.tw.
7 Acupressure.tw.
8 electro acupuncture.tw.
9 needling.tw.
10 Shu.tw.
11 (shiatsu or tui na).tw.
12 or/1-11
13 exp female infertility/ or exp ovary insufficiency/ or exp uterine tube occlusion/
14 (female$ adj3 subfertility).tw.
15 (female$ adj3 infertility).tw.
16 (women adj3 subfertility).tw.
17 (women adj3 infertility).tw.
18 female$ fertility.tw.
19 (women adj1 fertility).tw.
20 (in vitro fertilisation or intracytoplasmic sperm injection$).tw.
21 intrauterine insemination$.tw.
22 (ivf or icsi or iui).tw.
23 in vitro fertilization.tw.
24 Artificial reproduc$ technique$.tw.
25 exp infertility therapy/ or exp artificial insemination/ or exp fertilization in vitro/ or exp intracytoplasmic sperm injection/ or exp intrauterine insemination/
26 Assisted reproduc$ technique$.tw.
27 Clinical Trial/
28 Randomized Controlled Trial/
29 exp randomization/
30 Single Blind Procedure/
31 Double Blind Procedure/
32 Crossover Procedure/
33 Placebo/
34 Randomi?ed controlled trial$.tw.
35 Rct.tw.
36 random allocation.tw.
37 randomly allocated.tw.
38 allocated randomly.tw.
39 (allocated adj2 random).tw.
40 Single blind$.tw.
41 Double blind$.tw.
42 ((treble or triple) adj blind$).tw.
43 placebo$.tw.
44 prospective study/
45 or/27-44
46 case study/
47 case report.tw.
48 abstract report/ or letter/
49 or/46-48
50 45 not 49
51 (2009$ or 2010$).em.
52 or/13-26
53 12 and 50 and 51 and 52

 

Appendix 6. PsycINFO search strategy (Ovid)

1 exp acupuncture/
2 Acupuncture.tw.
3 electroacupuncture.tw.
4 meridian$.tw.
5 moxi$.tw.
6 Acup$ Point$.tw.
7 Acupressure.tw.
8 electro acupuncture.tw.
9 needling.tw.
10 Shu.tw.
11 (shiatsu or tui na).tw.
12 or/1-11
13 exp infertility/
14 (female$ adj3 subfertility).tw.
15 (female$ adj3 infertility).tw.
16 (women adj3 subfertility).tw.
17 (women adj3 infertility).tw.
18 female$ fertility.tw.
19 (women adj1 fertility).tw.
20 (in vitro fertilisation or intracytoplasmic sperm injection$).tw.
21 intrauterine insemination$.tw.
22 (ivf or icsi or iui).tw.
23 in vitro fertilization.tw.
24 exp reproductive technology/
25 or/13-24
26 12 and 25

 

Contributions of authors

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Acknowledgements
  6. Appendices
  7. Contributions of authors
  8. Declarations of interest
  9. Sources of support

XZ: conceptualised and wrote the protocol. She will search the Chinese databases, review trials and perform data extraction, data interpretation and assessment. She will jointly write the review.

HN: commented on and assisted with development of the protocol. She will also review trials, specifically publications in English. She will contribute to data interpretation and perform data assessment. She will also jointly write the review.

DL: commented on and assisted with development of the protocol. He will also review trials and perform data extraction jointly. He will contribute to data interpretation and perform data assessment. He will also jointly write the review.

 

Declarations of interest

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Acknowledgements
  6. Appendices
  7. Contributions of authors
  8. Declarations of interest
  9. Sources of support

None known.

 

Sources of support

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Acknowledgements
  6. Appendices
  7. Contributions of authors
  8. Declarations of interest
  9. Sources of support
 

Internal sources

  • Cochrane Menstrual Disorders and Subfertility Group, New Zealand.

 

External sources

  • University of Western Sydney, Australia.

References

Additional references

  1. Top of page
  2. Abstract
  3. Background
  4. Objectives
  5. Methods
  6. Acknowledgements
  7. Appendices
  8. Contributions of authors
  9. Declarations of interest
  10. Sources of support
  11. Additional references
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