Acupuncture for women undergoing in vitro fertilization: An updated systematic review and meta-analysis with trial sequential analysis

Background: In vitro fertilization (IVF) is a widely utilized assisted reproductive technology, but its success rates remain suboptimal due to various physiological and psychological factors. Acupuncture, as a complementary therapy, has been proposed to improve reproductive outcomes and alleviate associated pain and anxiety. Objective: To evaluate the effectiveness and safety of acupuncture as an adjunctive treatment for women undergoing IVF, focusing on reproductive outcomes, pain reduction, and anxiety alleviation. Methods: Five English databases were searched up to June 20th, 2024. Manual acupuncture or electro-acupuncture was used solely as a complementary adjuvant in the experimental groups, and control interventions were sham acupuncture or blank (wait-list) control. Systematic reviews and meta-analyses were conducted based on the Cochrane systematic review method, and trial sequential analyses were performed. Meta-influence analyses, meta-regression and subgroup-analyses were performed for exploration of heterogeneity and related variables. Egger's together with trim and fill tests were conducted for evaluation of publication bias. The quality of the results was assessed, and correlation coefficient and cluster analyses were also performed. Results: Finally, 42 trials identified from 37 published articles, involving 7400 participants, were included, representing diverse populations worldwide. Compared to sham acupuncture and blank controls, acupuncture significantly (P < 0.05) improved biochemical pregnancy rate (RR = 1.28, 95 % CI: 1.04-1.57) and clinical pregnancy rates (RR = 1.19, 95 % CI: 1.06-1.34). Additionally, acupuncture was associated with better pain management during surgery and reduced anxiety levels. Acupuncture-specific adverse events were reported in eight of 42 trials, primarily mild to moderate local reactions. However, a significantly higher early miscarriage rate was observed in the acupuncture groups (RR = 1.51, 95 % CI: 1.10-2.08). Conclusions: Acupuncture may improve certain reproductive outcomes and alleviate pain and anxiety in women undergoing IVF. However, the potential risk of early miscarriage warrants caution, and further rigorous trials are needed to confirm these findings. Registration: PROSPERO registration number CRD42020206012.