Acupuncture in patients with the poor ovarian response on IVF-ET: A systematic review and network meta-analysis

Background: Acupuncture has been increasingly studied as an adjunctive treatment strategy for improving pregnancy outcomes in patients with poor ovarian response (POR). However, the effectiveness of different acupuncture types remains controversial. The purpose of this paper was to assess the effects of transcutaneous electrical acupoint stimulation (TEAS), manual acupuncture (MA) and electroacupuncture (EA) on the pregnancy outcomes of patients with POR who underwent in vitro fertilization and embryo transplantation (IVF-ET) in order to clarify the differences in efficacy of the different acupuncture methods and to provide scientific evidence for the clinic. Methods: We searched 8 databases up to September 10, 2023. We included randomized controlled trials (RCTs) of the use of TEAS, MA or EA before IVF-ET to improve pregnancy outcomes in patients with POR, with the control group using only the conventional controlled ovarian stimulation protocol. The Cochrane Risk of Bias Assessment Tool was used to evaluate the methodological quality of the included studies. Surfaces under the cumulative ranking curves (SUCRAs) were used to provide summary statistics for the cumulative ranking of each outcome indicator. Results: Fifteen RCTs (1195 women) were included in a network meta-analysis. TEAS was superior to EA [mean difference (MD) = 1.85, 95% confidence intervals (CI) = (0.86, 2.84)], MA [MD = 2.31, 95% CI = (1.43, 3.19)] and control [MD = 2.22, 95% CI = (1.59, 2.85)] in increasing the number of oocytes. TEAS was superior to MA [MD = 0.99, 95% CI = (0.32, 1.65)], EA [MD = 1.61, 95% CI = (0.55, 2.67)] and control [MD = 1.46, 95% CI = (1.06, 1.86)] in terms of increasing antral follicle count. MA was superior to control [MD = 0.66, 95% CI = (0.08, 1.25)] in increasing the number of mature oocytes. The results of the remaining treatments were similar when the 2 groups were compared. Conclusion: From the current evidence, the adjunctive use of acupuncture prior to IVF all have positive effects and a high safety profile in improving pregnancy outcomes in patients with POR, and TEAS appears to be more promising. However, there is still insufficient evidence of differences between acupuncture methods in improving clinical pregnancy rates.