Infertility, defined as the inability to achieve conception through natural means, represents a significant global health issue impacting individuals globally. Traditional Chinese Medicine, particularly acupuncture, has gained attention as a potential complementary therapy for infertility. This review examines the efficacy of acupuncture in treating both female and male infertility, analyzing current systematic evidence and underlying mechanisms.
For female infertility, acupuncture has shown promising results in conditions such as anovulatory infertility, polycystic ovary syndrome, endometriosis, and improving endometrial receptivity. Evidence suggests that acupuncture alone or in combination with conventional treatments can enhance pregnancy rates, ovulation rates, and endometrial thickness, although findings are sometimes inconclusive due to methodological limitations. Acupuncture appears to modulate reproductive hormones, improve ovarian function, and facilitate embryo implantation, offering a valuable therapeutic option for women.
In male infertility, acupuncture has demonstrated potential benefits in enhancing sperm quality, balancing hormones, and reducing testicular damage caused by abnormal hormone levels. Studies indicate that acupuncture may improve sperm motility, concentration, and overall semen quality by regulating endocrine functions and mitigating apoptosis in germ cells. Despite promising outcomes, the quality of existing studies varies, and further research with robust methodologies is necessary.
This review highlights the potential of acupuncture as a safe, non-invasive, and effective adjunctive therapy for infertility. Integrating Traditional Chinese Medicine principles with modern medical practices could lead to more personalized and comprehensive infertility treatments, enhancing patient well-being and reproductive outcomes. Future research should focus on addressing current study limitations and further elucidating acupuncture's mechanisms in infertility treatment.
La infertilidad, definida como la incapacidad de lograr la concepción por medios naturales, representa un problema importante de salud mundial que afecta a personas en todo el globo. La Medicina Tradicional China, particularmente la acupuntura, ha ganado atención como una posible terapia complementaria para la infertilidad. Esta revisión examina la eficacia de la acupuntura en el tratamiento de la infertilidad tanto femenina como masculina, analizando la evidencia sistemática actual y los mecanismos subyacentes.
En la infertilidad femenina, la acupuntura ha mostrado resultados prometedores en condiciones como la infertilidad anovulatoria, el síndrome de ovario poliquístico, la endometriosis y la mejora de la receptividad endometrial. La evidencia sugiere que la acupuntura sola o en combinación con tratamientos convencionales puede aumentar las tasas de embarazo, las tasas de ovulación y el grosor del endometrio, aunque los hallazgos a veces no son concluyentes debido a limitaciones metodológicas. La acupuntura parece modular las hormonas reproductivas, mejorar la función ovárica y facilitar la implantación del embrión, ofreciendo una opción terapéutica valiosa para las mujeres.
En la infertilidad masculina, la acupuntura ha demostrado beneficios potenciales para mejorar la calidad del esperma, equilibrar las hormonas y reducir el daño testicular causado por niveles hormonales anormales. Los estudios indican que la acupuntura puede mejorar la motilidad, la concentración y la calidad general del semen del esperma al regular las funciones endocrinas y mitigar la apoptosis en las células germinales. A pesar de los resultados prometedores, la calidad de los estudios existentes varía, y se necesita más investigación con metodologías sólidas.
Esta revisión destaca el potencial de la acupuntura como una terapia complementaria segura, no invasiva y eficaz para la infertilidad. La integración de los principios de la Medicina Tradicional China con las prácticas médicas modernas podría conducir a tratamientos de infertilidad más personalizados e integrales, mejorando el bienestar del paciente y los resultados reproductivos. La investigación futura debería centrarse en abordar las limitaciones actuales de los estudios y elucidar aún más los mecanismos de la acupuntura en el tratamiento de la infertilidad.
Infertility denotes the incapacity of an individual to achieve conception via natural processes, which it is not the norm for a healthy adult.1–3 As stated by the World Health Organization,4 infertility emerges as a major global health issue, impacting not only the fertility rate but also exerting influence on population growth rate. To the individual, infertility may also contribute to economic and psychosocial strains.5–7
To assist in global health issues such as this, there is a pressing need to explore complementary techniques that might assist in improving outcomes. One of those options is traditional Chinese medicine which is a holistic medical system that looks at health as a cooperative state of internal biological functions that interact with each other.8 Its specific theories and philosophies are usually considered an obstacle to scientific understanding however, there has been an ongoing study to clarify the concepts in the light of western medical science.9–13 As well, traditional Chinese medicine may also offer solutions for the concept of “integrative medicine” as it is usually considered a promising complement to Western conventional medicine.14–20
Acupuncture, an increasingly researched technique of Traditional Chinese Medicine,21–24 is characterized as the insertion of small needles into points located on the body.8,19,25 On the other hand, electroacupuncture is a modern variation of acupuncture and involves the electrical stimulation of the needles,8 providing the advantage of precisely control stimulation levels.26 Overall, and in the holistic sense of traditional Chinese medicine, acupuncture aims to regulate the nervous, endocrine and exocrine, and circulatory systems and achieve a healthy state of well-being.27
In order to understand whether acupuncture may be a valuable technique for the treatment of infertility, this review aims to summarize and explore the existing evidence on the topic. It aims to provide an overview about the issue considering male and female infertility and analyze clinical effectiveness and applied methodologies.
Female infertilityFemale infertility can arise from several factors, encompassing menstrual irregularities, endometriosis, pelvic adhesions, ovulatory dysfunctions, tubal obstructions, hyperprolactinemia, and uterine anomalies.4,28 Specifically, congenital gonadal dysgenesis, hyperprolactinemia, diminished ovarian reserve, polycystic ovarian syndrome, luteinized unruptured follicle syndrome, and chronic anovulation are disorders that significantly contribute to infertility.29
Usually, medical treatments involve the use of fertility medications, surgical interventions, in vitro fertilization, and other assisted reproductive technologies.30–33 Commonly employed medications in clinical practice comprise clomiphene citrate, human chorionic gonadotropin, follicle-stimulating hormone, human menopausal gonadotropin, gonadotropin-releasing hormone and analogs, bromocriptine, and cabergoline,34–40 which may elicit a range of physical and psychological adverse effects.41,42 Moreover, in vitro fertilization treatments are associated with substantial financial and emotional burdens for patients.43
Current systematic evidence of acupuncture for female infertilityThe meta-analysis conducted by Gao et al.44 aimed to assess the effectiveness of acupuncture alone or in combination with clomiphene citrate compared to clomiphene alone for anovulatory infertility. Interestingly, when acupuncture was utilized alongside clomiphene citrate as an adjunct therapy, no significant differences were observed in pregnancy rates, ovulation rates, or pregnancy loss compared to clomiphene citrate alone. However, acupuncture administered as a standalone treatment exhibited promising outcomes. Specifically, it demonstrated superior effects in enhancing pregnancy rates and maximum follicular diameter compared to clomiphene citrate alone. Furthermore, statistical analysis indicated a reduction in the rate of pregnancy loss when acupuncture was used independently. These findings highlight the potential of acupuncture as a beneficial therapeutic approach for female anovulatory infertility, warranting further exploration and clinical consideration.
Despite anovulation accounting for approximately one-third of infertility cases among couples seeking treatment at infertility clinics, polycystic ovary syndrome is responsible for 90% of these cases.45
Therefore, and focusing on this highly prevalent cause of anovulatory infertility, a Cochrane database systematic review by Lim et al.46 aimed to assess the effectiveness and safety of acupuncture treatment for anovulatory women with polycystic ovarian syndrome. According to the results of the review, there was a low volume of studies to be analyzed (8 included) and very heterogeneous research methodologies. Accordingly, the effect of acupuncture compared to sham acupuncture for live birth rate, multiple pregnancy rate, ovulation rate, clinical pregnancy, miscarriage rate, and menstrual cycle restoration is uncertain. While acupuncture may have improved regular menstrual periods, it likely worsened side effects compared to sham acupuncture. However, and as noted in the work of Rodrigues et al.,8 creating a sham control for practices like acupuncture often proves challenging, requiring adjustments in methods and assessments.47,48 The use of inappropriate sham interventions can result in confusing and misleading results, potentially leading to an underestimation of the techniques and introducing bias against them.49
When compared to other interventions such as physical exercise, relaxation and clomiphene, results are also unclear regarding the acupuncture effect due to the lack of research. However, results suggest that acupuncture can possibly be favorable over physical exercise for managing the menstrual period regularity, over relaxation for ovulation rate, over conventional treatment (clomiphene) also for regulating the menstrual cycle, and over conventional treatment (Diane-35) for ovulation rate and menstrual restoration rate.
According to the authors, evidence remains insufficient to endorse acupuncture as a treatment for ovulation disorders in women with polycystic ovarian syndrome.
Endometriosis is a chronic inflammatory disorder that relies on estrogen and impacts 5% to 15% of women of reproductive age, resulting in infertility and pain.50,51 In this context, Xu et al.52 conducted a systematic review and meta-analysis to understand the possible role of acupuncture in this condition. Of the results presented by the authors and most relevant to our topic, acupuncture was suggested to reduce serum CA-125 (Cancer antigen 125) levels in women with endometriosis. Serum CA-125 levels are elevated in these patients53 and seem positively correlated with the severity of the disease.54,55 While further evidence is required, these findings imply that acupuncture could play a role in the management of endometriosis. By potentially ameliorating the condition, acupuncture might also contribute to alleviating associated infertility.
Endometrial receptivity is intricately linked with infertility, as a favorable endometrial receptivity is essential for the successful implantation of a blastocyst.56 Approximately two-thirds of implantation failures in in vitro fertilization-embryo implantation (IVF-ET) procedures are attributed to inadequate endometrial receptivity and optimizing endometrial receptivity enhances implantation success rate.57,58
Therefore, the meta-analysis of Zhong et al.59 summarized and evaluated the evidence of randomized controlled trials using acupuncture to improve endometrial receptivity.
In their study, these researchers found that compared with medication, sham acupuncture or physiotherapy, acupuncture might improve pregnancy rate and embryo transfer rate, increase trilinear endometrium, thicken endometrium, reduce resistive index (RI), among improving other associated parameters. These results suggest that acupuncture is a promising intervention to assist modern IVF-ET procedures.
In contrast, Yun et al.60 systematically reviewed evidence of acupuncture for infertile women without undergoing assisted reproductive techniques. Results showed that acupuncture treatment significantly improved the pregnancy rate compared to the control group. These improvement seem to be regardless of the intervention type: acupuncture alone, acupuncture combined with Western medicine, acupuncture combined with Chinese phytopharmacology, or a combination of acupuncture with both Chinese and Western pharmacology. Improvement was observed across various infertility types, including polycystic ovary syndrome, tubal infertility, ovulatory disorders, and other factors. Additionally, acupuncture led to increased ovulation rates and endometrial thickness, along with decreased luteinizing hormone levels and fewer adverse effects. Therefore, evidence suggest that acupuncture may be a promising intervention in the integrative medicine scenario for infertile women not undergoing assisted reproductive techniques.
Acupuncture mechanisms in female infertilityAccording to,61 The therapeutic impact of acupuncture on female infertility primarily targets three key areas: reproductive endocrine, follicular development, and embryo implantation.
In the follicular phase, basic reproductive hormones are at low levels, prompting menstruation upon estrogen and progesterone withdrawal. Low E2 (estradiol) and P (progesterone) levels stimulate GnRH (Gonadotropin-releasing hormone) secretion, fostering Gn (Gonadotropin) (FSH (Follicle-stimulating hormone) and LH (luteinizing hormone)) release, crucial for follicle development and subsequent E2 and P secretion. These hormones facilitate endometrial growth, essential for embryo acceptance. This cascade ensures synchronized follicular and endometrial development vital for pregnancy. In infertile women, high Gn levels hinder follicular growth, disrupting hormone balance and ovulation regularity, leading to infertility. Acupuncture restores normal hormone levels by decreasing GnRH, FSH, and LH while increasing E2 and P,61–65 thus promoting regular reproductive system function and enhancing fertility.
Improving ovarian function involves mitigating granulosa cell apoptosis within follicles and enhancing the ovarian environment. Granulosa cells play a vital role in providing nutrients for oocyte maturation during follicular development. Acupuncture showed to be able to modulate the expression of BCL-2 (B-cell lymphoma-2),65,66 decreasing apoptosis, and thus supporting follicular growth. Additionally, acupuncture can regulate factors like NGF (Nerve growth factor), CRF (Corticotropin releasing factor), and ET-1 (Endothelin-1) to reduce ovarian inflammation and enhance ovarian blood supply,67–69 fostering a conducive environment for follicular development.
Finally, embryo implantation, the crucial process of forming a biological connection between the embryo and endometrial microenvironment, can be facilitated by acupuncture through three main mechanisms. Firstly, acupuncture adjusts autoimmunity, enhancing maternal tolerance to embryos by upregulating CCL2 (CC chemokine subfamily L2) expression,70 thereby mitigating immune rejection. Secondly, it facilitates trophoblast invasion into decidual tissue by increasing CXCL8 (CXC chemokine subfamily L8) and MMP-2 expression,70 establishing physical embryo-endometrium connections. Thirdly, acupuncture promotes angiogenesis through elevated VEGF, ANG2, and PGF expression, facilitating nutrient exchange between mother and embryo. Additionally, acupuncture aids embryonic development within the endometrium by boosting IGF-1 (insulin growth fact-1) expression.71
Male infertilityMale infertility can stem from various factors including biological, behavioral and lifestyle influences, environmental exposures, and socio-demographic variables.72 The information is explored and summarized in Table 1.
Male infertility causes and risk factors according to Okonofua et al.72
| Biological factors | Genetic factors |
| Uro-genital infections | |
| Varicoceles | |
| Behavioral risk factors | Smoking |
| Alcohol intake | |
| Inappropriate BMI | |
| Sexual behavior | |
| Exposure to drugs | |
| Environmental risk factors | Exposure to chemicals |
| Exposure to pesticides | |
| Exposure to mycotoxins | |
| Socio-Demographic factors | Increasing age |
However, the etiology of a great proportion of male patients with infertility cannot be determined46,73.
Despite stigma associated with the topic, according to Agarwal et al.74 there are more than 30 million men suffering from infertility.
In addition to increasing the burden on women, the failure to assess male infertility frequently results in the oversight of numerous associated conditions such as cardiovascular, autoimmune and metabolic disorders, but also cancer and even death.75 Hence, there is an urgent need to raise awareness and implement enhancements to facilitate early detection and effective management of male infertility.
The treatment of male infertility necessitates a tailored approach based on individual etiology and requirements. It is imperative for couples to seek high-quality counseling to undergo proper diagnostic testing and determine the most suitable therapy, which may include pharmacological interventions, surgical procedures, or assisted reproductive technologies.76 Nevertheless, certain methods remain controversial, such as the indications and surgical techniques for varicocele repair.77,78 Furthermore, these therapeutic approaches come with limitations, including a low live-birth rate, high costs, lengthy treatment cycles, and potential adverse reactions.79–82
Current systematic evidence of acupuncture for male infertilityThe study of He et al.83 aimed to evaluate acupuncture as a treatment for male infertility. In this systematic review, the authors concluded that acupuncture cure rate, sperm concentration and grade, and therapeutic effectiveness is comparable to Chinese herbal medicine (CHM) and superior to western medicine (WM). However, acupuncture combined with CHM was superior compared to CHM or WM alone, as well as acupuncture combined with WM was superior to WM alone. Despite the promising results, the authors note that the quality of studies need to be improved in the future.
Specially regarding the previous authors' conclusion that acupuncture is distinctively effective in improving sperm quality, Jerng et al.84 conducted a systematic review to assess the effectiveness and safety of acupuncture for poor semen quality in infertile men. Despite the low number of studies and overall quality, results showed that acupuncture might increase the percentage of sperm motility and concentration, agreeing with the study of He et al83 It was also reported that no adverse events were observed among participants receiving acupuncture. The condition where there is a low concentration of sperm (oligozoospermia) and motility (asthenozoospermia) is usually called oligoasthenozoospermia. Considering the presence of both factors, You et al.85 designed a study to assess the evidence on the effect of acupuncture in male oligoasthenozoospermia. The twelve-study systematic review concluded that acupuncture alone or in combination with CHM or WM may be effective in improving sperm quality, supporting the results of the two previous studies reported in this review.
Building upon previous research, Jia et al.86 explored the effects of acupuncture on sperm parameters as well. In this study, acupuncture did not show a clear superiority in improving sperm motility, sperm concentration, or semen volume when compared to placebo acupuncture. However, and as stated before in this review, designing sham controls may not be effective in acupuncture research. In fact, the results pointed out to a comparable effect of acupuncture and conventional treatment in improving sperm motility, sperm concentration, or semen volume. As well, adjuvant acupuncture alongside medication may enhance the effect of medication on improving sperm motility and sperm concentration.
Finally, Chen et al.87 designed a network meta-analysis to investigate the efficacy of non-pharmaceutical interventions on sperm quality. The study focused on the assessment of several techniques such as acupuncture, exercise, lycopene, ω-3 fatty acids, CoQ10, zinc, vitamins, selenium and carnitine. According to the results, acupuncture was shown to be superior to placebo on improving sperm motility and overall being a non-pharmacological intervention that can effectively improve sperm quality. It was suggested that acupuncture may be utilized in the treatment of male infertility.
Acupuncture mechanisms in male infertilityIt is known that the endocrine system, crucial for reproductive function, is regulated by the hypothalamic–pituitary-gonadal axis. GnRH from the hypothalamus stimulates the secretion of FSH and LH from the anterior pituitary. In men, FSH acts on Sertoli cells, promoting spermatogonial maturation, while LH stimulates Leydig cells to produce testosterone, vital for spermatogenesis. Abnormal FSH and LH levels can decrease testosterone synthesis, affecting sperm production and fertility. Low testosterone levels may lead to reduced sperm production and fertility issues.88–90
Furthermore, elevated levels of FSH and LH in men with low fertility are linked to damage in the spermatogenic epithelium and stromal cells of testicular seminiferous tubules.91 Studies have shown that electroacupuncture can effectively reduce FSH and LH levels in rats with induced spermatogenesis dysfunction,92 specific acupuncture techniques could reduce LH levels in rats,93 while acupuncture in patients with oligoasthenospermia also decreased FSH and LH levels.94,95 This suggests acupuncture may mitigate damage to testicular cells caused by abnormal FSH and LH levels, potentially improving male fertility.96 Additionally, acupuncture can increase androgen levels. Studies on rats with partial androgen deficiency syndrome found that acupuncture increased total and free testosterone levels and improved testicular pathology.97,98 This effect was attributed to increased expression of cytochrome P450 side-chain lyase, steroid growth factor-1, and 17β-hydroxysteroid dehydrogenase 3 in Leydig cells and Sertoli cells.
As well, it has been suggested that poor sperm parameters are associated with changes in calcium and integrin-binding protein 1, along with the cell cycle regulator cyclin-dependent kinase 1. Imbalances in CDK1 or other cell cycle regulators may disrupt Sertoli cell proliferation intervals, leading to an imbalance between Sertoli cells and germ cells, increased germ cell apoptosis, and spermatogenesis defects.99 A clinical study100 showed that transcutaneous electrical acupoint stimulation improved sperm count and motility in patients with abnormal semen parameters. This improvement was linked to increased seminal plasma zinc, N-acetylglucosaminidase, and fructose levels, alongside upregulated CIB1 and downregulated CDK1 expression. Sertoli cells, crucial for supporting germ cells during spermatogenesis, are affected by physical and chemical alterations in their cytoskeleton, which can disrupt spermatogenesis.101,102 Additionally, electroacupuncture has shown to increase sperm count, weight, concentration, and motility, with improvements linked to altered expression of SC cytoskeletal proteins and enhanced germ cell proliferation with reduced apoptosis.103 electroacupuncture mechanism involves enhancing germ cell proliferation by improving Sertoli cell function, facilitating spermatogenesis recovery and normalization of semen parameters in subfertile men.104 Furthermore, research identified a novel mechanism for asthenozoospermia pathogenesis involving the downregulation of CatSper channels in sperm.105 In this study, electroacupuncture was found beneficial in restoring sperm function by inducing the upregulation of CatSper channels.
Final remarks and considerationsInfertility poses significant challenges to individuals and couples worldwide, impacting not only their physical health but also their emotional well-being and social relationships. According to our review, Traditional Chinese Medicine, particularly acupuncture, has emerged as a promising adjunctive therapy in the management of infertility, offering potential benefits for both male and female patients. This review has provided a comprehensive overview of the current evidence regarding the efficacy of acupuncture in addressing infertility, focusing on its application in female and male infertility.
In the realm of female infertility, acupuncture has shown promising results in various conditions such as anovulatory infertility, polycystic ovary syndrome, endometriosis, and improving endometrial receptivity. While some studies have reported positive outcomes, others have shown inconclusive results, underscoring the need for further research with rigorous methodologies and larger sample sizes. Nevertheless, acupuncture appears to offer a valuable therapeutic option for women seeking complementary treatments for infertility, especially when used in conjunction with conventional medical interventions.
For male infertility, acupuncture has demonstrated potential benefits in improving sperm quality, enhancing hormonal balance, and mitigating testicular damage caused by abnormal hormone levels. Studies have suggested that acupuncture may modulate key factors involved in spermatogenesis, such as cytochrome P450 side-chain lyase, steroid growth factor-1, and 17β-hydroxysteroid dehydrogenase 3, thereby promoting optimal reproductive function. Moreover, acupuncture has been associated with reduced germ cell apoptosis, improved semen parameters, and restoration of sperm function, offering hope for men struggling with infertility.
Despite the promising findings, it is essential to acknowledge the limitations of existing studies, including small sample sizes, heterogeneity in methodologies, and the lack of insufficient quality of overall studies included in the analyzed systematic reviews. Future research efforts should focus on addressing these challenges and further elucidate the underlying mechanisms of acupuncture in infertility treatment. Additionally, collaborative interdisciplinary approaches involving traditional Chinese medicine practitioners, reproductive endocrinologists, andrologists, and other healthcare professionals are crucial for optimizing patient care and achieving successful reproductive outcomes.
ConclusionsAcupuncture holds considerable promise as a safe, non-invasive, and potentially effective therapeutic modality for addressing infertility in both men and women. By seriously considering the holistic principles of traditional Chinese medicine and integrating them with modern medical practices, it is possible to build more personalized and comprehensive infertility treatments that prioritize patient well-being and reproductive health.
FundingThis research received no external funding.
Ethical approvalThis review does not require ethical approval.