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Another Acupuncture Claim

News bulletin on BBC NEWS International version, 8 Feruary 2008:“Acupuncture ‘boosts IVF chances.’ Acupuncture may increase the success rates of fertility treatment, according to a study. “

(Manheimer E, Zhang G, Udoff L, Haramati A, Langenberg P, Berman BM, Bouter LM. Effects of acupuncture on rates of pregnancy and live birth among women undergoing in vitro fertilisation: systematic review and meta-analysis. BMJ. 2008 Feb 7)

First off, how plausible is the claim? The press release states that acupuncture had been used in China fior thousands of years for infertility. Has it? No medical historian writing I have seen made such an interpretation of ancient texts. Maybe I missed something…possible. But acupuncture was not used for specific disorders or purposes, but was used as a sort of panacea to cause balance of either the Yin and Yang or of the relationship of the individual with the 5 elements and the cosmos and the earth. There is nothing specific in claims of acupuncture in traditional Chinese Medicine history. Who gave the news people that misleading lead-in?

Second, what is the plausibility that acupuncture could possibly affect a laboratory procedure on tissue removed from the subject, regardless of timing? Negligible to none. There is no consistent and credible information that acupuncture is effective for anything, except as a conditiong agent for perception of symptoms.

So, does acupuncture increase the success of IVF?

This study, making international news wires, was not another randomized clinical trial (RCT,) but a Systematic Review (SR) of previous trials. We have several layers of potential error to contend with: 1) The quality and accuracy of each RCT, 2) The quality and accuracy of the SR itself, 3) The accuracy of the news release, which emanates from publicity departments of the respective universities, 4) The relevance and selection of the quotations and the data.

Individual RCTs display yet another layer of potential error. Some of the difficulties in evaluating RCTs were delineated in Dr. Atwood’s review of homeopathy. They include the biases of the sponsoring organization, the heterogeneity of treatment and control subjects from one trial to another, differing end points, differing methods of pain and other symptom measurements, the problems of quantifying symptoms – which are multiple and difficult to overcome, differing (in this case) acupuncture techniques, and differing statistical analyses and expressions. Acupuncture studies are particularly prone to problems of breaking of the blinding. None of these is known to have been adequately controlled for in RCTs to date. Ioannidis in his now classic paper in PLoS Medicine 1996 listed a number of similar faults responsible for his thesis that most clinical results are false. (I would say, just erroneous.) Nevertheless, most positive acupuncture trials are defective and their results are unreliable.

As for sponsoring organizations, RCTs sponsored by pharmaceutical companies are generally suspect and show inordinate degrees of “efficacy.” So far, RCTs sponsored by the National Center for Complementary and Alternative Medicine, supplement companies, sectarian method treatment centers, ideologically oriented granting agencies, have not received the same attention for conflict of interest. They should. They all show an excess of “positive” trials for ineffective treatments.

As for SRs, no SR system accounts for those embedded biases. Nor is there an accepted, proved methodology for performing SRs. One count of different SR methods came to over twenty. Some have entry criteria for RCTs, which eliminate lower quality individual studies. Other SRs include as many studies as possible. Whichever general method is used, most SRs differ from one another as to which studies qualify for inclusion.

Not only that, there are no current universally accepted standards for RCT evaluation, or as to how the evaluators judge and negotiate their differences. Nor is there an accepted level or measure for when to declare a method effective or ineffective or indeterminate. Add to that the facts that there are no qualifications for systematic review reviewers – and worse, most reviewers of “CAM” or sectarian methods are the practitioners and advocates of those methods. Talk about biases…

We have been collecting Srs and analyzing the conclusions from varying subjects and treatment methods.

Comparing acupuncture Srs with those of anti-hypertensive drug efficacy, or with other ineffective methods shows an apparent bias in how results are reported, and their conclusions.

Regarding this BBC report, so far I have not seen the original paper, just the news release. Nevertheless, the release states an obvious clue that contradicts the headline conclusion, which I assume is the conclusion of the SR authors. The standard known success rate in the best of hands for in vitro fertilization (IVF) is about 25 percent. We went through this material in analyzing and reporting on the infamous Cha/Wirth report of positive results on IVF from distant prayer, now with mountains of evidence to have been fraudulent. In this acupuncture SR, the authors admit that in the most successful labs, there was no improvement in IVF success when subjects received acupuncture. Apparently, the successes came in labs in China which had lesser success rates before the study. There are several reasons why a success might be increased in a low success rate lab. Data selection would rise to the to the top, as would any study that allowed a timing bias – with comparisons of later vs. earlier data, which would allow improvement with experience and expertise development. Editors should require all raw data from those overseas labs.

One might ask, in view of that latter fact alone, why this article was accepted for publication, and why such a headline conclusion was allowed to be broadcast. The British Medical Journal seems to have been printing reports on sectarian medicine methods more frequently than have many other journals. The editorship recently changed and we had hoped for a significant change in that policy. Change is slow.

Posted in: Acupuncture, Clinical Trials, Energy Medicine, Science and the Media

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14 thoughts on “Another Acupuncture Claim

  1. novemberromeo says:

    Thank you for confirming my understanding of the paper in question. This dubious meta-analysis made the headlines in the UK on monday and I was writing nasty emails to the news presenters asking them to desist.

    BTW if you havent found the offending paper it can be seen at http://press.psprings.co.uk/bmj/february/ivf.pdf doi:10.1136/bmj.39471.430451.BE

  2. jonny_eh says:

    Am I seeing double or did you and David Gorski tackle the exact same issue?

  3. David Gorski says:

    We did, but there’s nothing wrong with that. There’s no reason why we co-bloggers can’t write about the same topic, particularly when it’s one this contentious. In any case, I read the paper and looked up some of the references cited.

    Also, I have been traveling and have no Internet access right now. (I’m in a Panera’s right now checking e-mail and the blog.) I won’t have Internet access again before tomorrow. Not having Internet access really, really sucks, especially for a blogger.

  4. Harriet Hall says:

    I think there is great value in having two people independently evaluate the same issue. It’s doubly reassuring when they reach the same conclusion by somewhat different routes. I’ll be commenting on another acupuncture article tomorrow, and my thoughts on that article mesh with Dr. Sampson’s and Dr. Gorski’s thoughts on this one.

    This is the real value of this blog: it’s not just the opinions of one person, and it’s not produced by consensus or agreement on policy. It is 5 independent medical minds of different backgrounds trying to think critically about important issues. I’d like to think that the fact that we almost always agree means we are all thinking clearly and evaluating the evidence objectively.

  5. daedalus2u says:

    There may well be a negative psychological effect of even bring up the subject of acupuncture in the context of IVF. How do they deal with the possibility that individuals choose to not be in such a trial because they believe acupuncture is woo?

    If it was me, and I had gone through the fertility treatments required to get to this point (multiple injections, multiple ultrasounds, and having spent tens of thousands of dollars), and the medical personnel bring up the concept of acupuncture, I am going to think “what kind of woo are these clowns selling?” Much of the confidence I had in their competence would simply evaporate.

    The trials can’t be “double blind” because the person doing the acupuncture either knows how to do “real” acupuncture and does it, or doesn’t do it. The person doing the acupuncture would know if it was real or not, and a savvy individual may well be able to pick up on the body language that the acupuncturist thought they were doing something bogus.

    It becomes a trial of how good an actor the acupuncturist is. If he/she is a bad actor, the trial would be expected to show positive results from the placebo effect.

    They should ask the subjects if they think they got the real acupuncture or the fake acupuncture. It may well be that thinking one is receiving authentic acupuncture treatments is where the effect lies.

  6. Blade says:

    Sorry I don’t have much time to reply to this article, I am a student in Oriental Medicine, my question is if nothing can be proven with acupuncture, how come, for example using point Zhi Yin (Bladder 67) on the little toe, on the bladder channel has a high (over 80%) success rate of turning a malpositioned fetus the right way – or head down? Is sham medicine so strong that a person is capable for such a thing just by imagining? If so, why do we have medicine at all? Maybe that’s how western medicine works too? They don’t provide any better proofs than that either. Lets just have the patients lie down and imagine that they are healed and have a nice day?

    Another thing: just a few weeks ago I started to acupuncture my girlfriend – whom before knowing me didn’t know anything about it – just using some general body strengthening methods, I asked her to tell me what exactly she feels. A couple of weeks later we had her daughter over – married, lives with husband in another town – she also didn’t know anything about acupuncture. I did the same exact procedure on her while my girlfriend was standing by and watching and the daughter was describing the exact same things that were happening inside her body. The same exact internal feelings occuring to here the same exact time intervals.

    If this is all sham medicine, what is the explanation to these?

  7. Blade says:

    I am mainly interested in an explanation from current medical science’s view what is exactly happening when stimulating point Zhi Yin (BL67) on the little toe ( http://www.acuxo.com/meridianPictures.asp?point=BL67&meridian=Bladder ) that turns a malpositioned fetus?

    Anyone up for the challenge? Please provide scientific proofs, feel free to use any means of sources and clinical trials. I will be waiting for the explanation.

    Thank you!

  8. Harriet Hall says:

    A rule I learned from Ray Hyman: don’t try to explain a phenomenon before establishing whether the phenomenon really exists. I think it is far more likely that the research is flawed than that toe-puncture can turn a fetus. Still it might be amusing to hear acupuncturist’s speculations, especially if any of them were amenable to testing…

  9. pmoran says:

    Statistical fluke? (the study has not been replicated and the differences were modest — 75% vs 62% cephalic presentations “during the 35th week and at delivery”).

    Other equally banal explanations exist: the study did not include a control group that underwent an equally intense program of periods of enforced stillness in a certain posture or who experienced other painful stimuli that may in some way encourage foetal mobility. It was thus not a strictly controlled clinical trial.

    As Harriet says, we are bound to consider all possible mundane explanations as to why it seemed to work, before invoking undemonstrable and extremely improbable processes or forces.

  10. Joe says:

    pmoran,

    I do not know where you got those numbers. When I went to the URL it gave a very short, strange set of statements, including:
    “…
    Contraindication: Do Not Needle If Pregnancy is known or suspected.


    Turns The Fetus
    Facilitates Childbirth and Labor”

    That is reminiscent of the dermatological, herbal prep that cautions “Not to be taken internally. Avoid contact with skin.”

  11. pmoran says:

    Oh, sorry, Joe. All this refers to a well-known study on moxibustion, actually published in the JAMA in 1998. I assumed most would know of it.

    Here is a site containing the abstract and a how-to section that presumably outlines the methods used in the study.

    http://www.birthinternational.com/articles/andrea13.html

  12. Joe says:

    pmoran,

    I wasn’t taking you to task. I would not have posted except I found it amusing that a procedure intended to turn a fetus should not be used during pregnancy!?

    I don’t know nuthin’ about birthin’ babies, Miss Scarlet.

    It is unfortunate that they did not have a placebo control in that study. It would have been quite simple to have the women sit for 20 minutes a day* and do something else. There is (was) an electromagnetic device that supposedly helped broken bones mend. As I recall, after many years someone noticed that it worked as well with the electricity ‘off.’ The healing was due to the periods of forced immobilization of the limb. Sorry, I read this casually, many years ago, and cannot find the source.

    *The JAMA abstract does not indicate the exact treatment; sitting for moxibustion 20 minutes per day was described in web article.

  13. @Blade,

    Drs. Hall and Moran are exactly correct: the difference between the intervention and control groups was modest (read: “not clinically significant”) and, even assuming it to be real, easily explained by mundane reasons or by chance. Other obvious objections to the trial, in addition to those mentioned by Dr. Moran, are that it was not blinded and there was no placebo, ie, sham moxibustion, given to “control” subjects. In their reply to subsequent letters to editor, the authors demonstrated a lack of understanding of the need for placebo treatment and for blinded observers and subjects. (See, if possible: http://jama.ama-assn.org/cgi/content/full/282/14/1329 )

    As implied by Dr. Moran, the lack of replication in the 10 years since the report is a compelling reason not to take the claim seriously.

    There is another compelling reason not to take that trial seriously: it emanated from China, one of the countries that for at least 30 years produced exclusively “positive” reports of acupuncture. See:

    http://dx.doi.org/10.1016/S0197-2456(97)00150-5

    Finally, please reconsider this part of your challenge: “Please provide scientific proofs…” The onus is not on the skeptic to disprove an extraordinary claim; the onus is on the claimant to provide compelling evidence in its favor. In the case of moxibustion of the little toe purportedly turning fetuses, this has not been done.

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