Acupuncture in patients with the poor ovarian response on IVF-ET: A systematic review and network meta-analysis
Liu et al. · Medicine · 2026
Evidence Level
MODERATEOBJECTIVE
To compare the efficacy of TEAS, manual acupuncture, and electroacupuncture in women with poor ovarian response in IVF
WHO
1,195 women with poor ovarian response undergoing IVF-ET
DURATION
2-3 menstrual cycles of treatment
POINTS
Points focused on the abdomen and kidney, spleen, and liver meridians
🔬 Study Design
TEAS
n=150
Transcutaneous electrical acupoint stimulation
Manual Acupuncture
n=200
Traditional manual needling
Electroacupuncture
n=245
Acupuncture with electrical stimulation
Control
n=600
Conventional ovarian stimulation only
📊 Results in numbers
TEAS superior in number of oocytes vs control
TEAS superior in antral follicle count vs control
Manual acupuncture superior in mature oocytes vs control
No significant difference in clinical pregnancy rate
📊 Outcome Comparison
Number of oocytes retrieved
This study showed that different types of acupuncture may help women with poor ovarian response during in vitro fertilization treatments. Electrical stimulation of acupuncture points (TEAS) showed the most promise for improving the number of oocytes. All acupuncture treatments were safe and well tolerated.
Article summary
Plain-language narrative summary
This network meta-analysis analyzed the efficacy of different acupuncture modalities as adjuvant therapy in women with poor ovarian response (POR) undergoing in vitro fertilization with embryo transfer (IVF-ET). The study included 15 randomized clinical trials with 1,195 participants, comparing transcutaneous electrical acupoint stimulation (TEAS), manual acupuncture (MA), and electroacupuncture (EA) versus conventional controlled ovarian stimulation. Poor ovarian response affects 9 to 24% of patients undergoing ovulation induction, resulting in low estrogen levels, high cycle cancellation rate, reduced number of oocytes, and low pregnancy rates. This condition represents a significant challenge in reproductive medicine, increasing the economic and psychological burden on patients.
The context of the study is particularly relevant given that previous systematic reviews on acupuncture in IVF have produced conflicting results, possibly due to heterogeneity among different types of acupuncture. The methodology employed a comprehensive search of eight databases through September 2023, including Chinese and international databases. Inclusion criteria covered randomized clinical trials that used TEAS, MA, or EA as adjuvant therapies before IVF-ET in patients with POR, compared with the conventional ovarian stimulation protocol. Primary outcomes included clinical pregnancy rate, while secondary outcomes evaluated number of oocytes, mature oocytes, anti-Müllerian hormone (AMH), follicle-stimulating hormone (FSH), and antral follicle count (AFC).
The results revealed that TEAS demonstrated significant superiority over EA, MA, and control in increasing the number of oocytes retrieved, with mean differences of 1.85, 2.31, and 2.22, respectively. For antral follicle count, TEAS was also superior to MA, EA, and control. Manual acupuncture proved superior to control only in increasing the number of mature oocytes. Interestingly, none of the acupuncture modalities showed statistically significant differences in clinical pregnancy rate compared with the control group, although TEAS presented the highest SUCRA value (72.8%).
The proposed mechanisms suggest that acupuncture may improve POR through multiple levels, systems, and targets, potentially involving several stages of the assisted reproduction process. TEAS, being a non-invasive technique, may be particularly suitable for patients with needle phobia. Studies indicate that women undergoing assisted reproduction are prone to anxiety, and up to 75.9% of infertile women experience central nervous system and hypothalamic-pituitary-ovarian axis dysfunction in response to adverse emotional stimuli. TEAS demonstrated significant benefits in regulating emotional disturbances, stimulating the release of central opioid peptides and neurotransmitters, promoting endometrial growth, and improving ovarian reserve function.
Clinical implications suggest that all studied acupuncture modalities have positive effects and a high safety profile in improving pregnancy outcomes in patients with POR. Safety analysis revealed minimal adverse effects, including rare cases of mild allergy with TEAS and subcutaneous hematomas with EA, all transient in nature. Limitations of the study include the lack of consensus on the definition of POR, different treatment frequencies among modalities, heterogeneity among included studies, and absence of data on live birth rates. Variability in diagnostic criteria for POR may have introduced significant heterogeneity, affecting the precision of the results.
Strengths
- 1First network meta-analysis comparing different acupuncture modalities for POR
- 2Robust sample with 1,195 participants from 15 studies
- 3Rigorous methodology following PRISMA-NMA guidelines
- 4High safety profile documented
- 5Analysis of multiple clinically relevant outcomes
Limitations
- 1Lack of consensus on the definition of poor ovarian response across studies
- 2Different treatment frequencies among modalities may have influenced results
- 3Absence of long-term data on live birth rates
- 4Impossibility of blinding due to the nature of the interventions
- 5Insufficient evidence for differences in clinical pregnancy rates
Expert Commentary
Prof. Dr. Hong Jin Pai
PhD in Sciences, University of São Paulo
▸ Clinical Relevance
Poor ovarian response remains one of the most frustrating problems in reproductive medicine, affecting between 9 and 24% of patients in induction cycles — and the therapeutic window for adjuvant interventions is narrow. This network meta-analysis, pooling 1,195 participants from 15 randomized trials, offers for the first time a comparative ranking among available acupuncture modalities, information that previously simply did not exist in the literature. For physicians working in assisted reproduction or receiving patients referred from IVF centers, the data on TEAS are particularly actionable: it is a non-invasive technique, applicable in an outpatient setting, with a treatment duration compatible with two to three menstrual cycles — a window that fits perfectly within the usual schedule for follicular puncture preparation. Patients with diminished ovarian reserve, elevated FSH, and a history of cycle cancellations form exactly the group that most seeks adjuvant alternatives and that can benefit from this approach within a structured multiprofessional medical protocol.
▸ Notable Findings
The most noteworthy finding is not just the superiority of TEAS over the other modalities, but the magnitude and consistency of this advantage in objective intermediate outcomes: mean difference of 2.22 additional oocytes retrieved compared with control and 1.46 additional antral follicles — gains that, in the context of a patient with low reserve, may be the difference between having or not having embryos available for transfer. SUCRA analysis ranked TEAS first for clinical pregnancy rate at 72.8%, even without reaching statistical significance for this outcome — which suggests a clinically relevant trend that larger samples may confirm. Another point that deserves attention is the proposed mechanism: modulation of the hypothalamic-pituitary-ovarian axis via release of opioid peptides and central neurotransmitters, with documented impact on the emotional component of infertility, given that up to 75.9% of infertile patients present HPO axis dysfunction mediated by stress. This repositions TEAS not only as an intervention on ovarian reserve, but as integrated management of a multidimensional condition.
▸ From My Experience
In my practice with patients referred from assisted reproduction services, I have observed that acupuncture as an adjuvant in IVF cycles arouses both excessive expectation and exaggerated skepticism — and this work helps calibrate both positions. I usually initiate treatment at least two cycles before scheduled puncture, which coincides with the protocol of the studies analyzed here. The response in terms of well-being sensation and anxiety reduction appears quickly, already in the first three to four sessions; the improvement in ovarian markers, when it occurs, is generally perceived by the reproduction specialist on the second or third follow-up ultrasound. At the Pain Center, where TEAS is also used for other indications, we empirically confirm its excellent tolerability profile — a finding that is repeated here. For patients with needle phobia, TEAS is the natural entry point. I do not indicate acupuncture as a substitute for the pharmacological stimulation protocol, but as an additional layer especially in those with a history of cycle cancellation and elevated emotional burden — a profile that, in my experience, is the one that responds most.
Full original article
Read the full scientific study
Medicine · 2026
DOI: 10.1097/MD.0000000000046728
Access original articleScientific Review
Marcus Yu Bin Pai, MD, PhD
CRM-SP: 158074 | RQE: 65523 · 65524 · 655241
PhD in Health Sciences, University of São Paulo. Board-certified in Pain Medicine, Physical Medicine and Rehabilitation, and Medical Acupuncture. Scientific review and curation of every entry in this library.
Learn more about the author →Medical disclaimer: This content is for educational purposes only and does not replace consultation, diagnosis, or treatment by a qualified professional. Some information may be assisted by artificial intelligence and is subject to inaccuracies. Always consult a physician.
Content reviewed by the medical team at CEIMEC — Integrated Centre for Chinese Medicine Studies, a reference in Medical Acupuncture for over 30 years.
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