Acupuncture: just a placebo?

Last week, there was yet another piece of research trumpeting the benefits of acupuncture; in this case, needling was said to relieve hot flushes in breast cancer patients by up to 50 per cent. The new study, unveiled at a conference in Berlin, follows similar claims that the ancient treatment can benefit those with arthritis, back pain, migraine and infertility. But is acupuncture really the miracle treatment it seems?

It appears to have become a fashionable cure-all, with 3,000 practitioners now regulated by the British Acupuncture Council. Earlier this year the highly respected British Medical Journal (BMJ) reported that acupuncture could increase IVF success rates by 65 per cent, based on analysis of seven separate trials involving 1,366 women. According to Chinese philosophy, acupuncture works by interfering at particular points along channels in our bodies, known as meridians, thereby enhancing the flow of life energy, known as Ch'i. Although the concepts of Ch'i and meridians make no sense in terms of science, medical researchers have been interested in testing the claims of acupuncture ever since the 1970s.

But in order to test the impact of acupuncture, one must disentangle the placebo effect (which means that as long as a patient believes that a treatment will work, then they are likely to respond positively). The best clinical trials involve two groups of patients: one receiving the real treatment, the other taking something that feels real, but which is ineffective. Researchers can then see if the new intervention offers any benefit beyond what is seen with the sham one. But how do you create a form of sham acupuncture? In recent years, researchers have developed three procedures. The first involves needling the patient at the wrong points on the skin, thereby missing the "meridians". In the second, acupuncturists insert the needles to shallow depths, again avoiding the meridian. The third procedure uses retractable needles: like theatrical daggers, the skin drives the needles back into the handle of the instrument, but the patient is none the wiser.

So how accurate were the trials analysed in the BMJ? The problem is that four out of the seven trials did not include a "sham" acupuncture group, but merely compared the effect of acupuncture with no acupuncture at all; any benefit could be due to the placebo effect and therefore these trials should be ignored. When focusing on the remaining three trials which had included such a sham group, the results are less than impressive. Two out of three failed to show that real acupuncture offers any significant benefit (in terms of likelihood of pregnancy) beyond the fake treatment. The sensible conclusion is that acupuncture is still unproven in terms of increasing IVF success rates. So it is worth avoiding acupuncture in the context of IVF, since 10 per cent of patients complain of pain, bleeding or bruising, and some even experience fainting, dizziness, nausea or vomiting. These adverse effects are not serious, but the known risks outweigh the unproven benefits.

The needles helped me conceive, says Lydia Slater. As a doctor's daughter, I was brought up to despise alternative medicine. But then, about five years ago, I found myself struggling with a variety of conditions that my GP seemed unable to treat. I had developed irritable bowel syndrome; I had put on weight, was unable to sleep and full of unspecified rage at my unexplained failure to conceive. All that modern medicine seemed to offer was a course of soporific antidepressants. Then I met a friend who was being treated for polycystic ovary syndrome by a Harley Street acupuncturist, a practitioner who, incidentally, specialised in unexplained infertility. I booked myself in, without telling my parents. The weekly sessions weren't cheap - some £80 a time. Initially, I was scared of the needles, but the acupuncturist was so skilled I felt nothing. I soon had them sticking out of my ears and in my finger joints. As the needle went in, I sometimes felt a violent jolt of electricity in one limb, or flashing along my body's nerve networks. Often, I would be visited by a burst of exhilaration or was suffused with a feeling of calm. The experience was positively addictive. I increased the sessions, sometimes to twice a week, which I could ill afford. Instead, I gave up shopping and eating out. The effects were startling: first, the IBS cleared up; then I ceased to comfort-eat and lost weight. I booked sessions to coincide with difficult situations, such as prior to a work meeting at which I had to negotiate a new contract. The acupuncturist told me that he would arrange the needles so as to boost my oestrogen levels, reduce stress and thus improve my chances of conceiving. It sounded like mumbo jumbo, but although I'm normally diffident, I found myself storming into the office and insisting on precisely the deal I was after. It was about the same time that I discovered I was pregnant. I now have two daughters, Asya, nearly four, and Rosie, two. I can't believe that my return to health can be attributed to a placebo effect. So many people I know can attest to the benefits of acupuncture: it has helped friends with everything from healing torn muscles to boosting low self-esteem. These days when I'm ill, I still go to my GP. But if a problem is nebulous or intractable, I'll be straight back to the needles.

By Simon Singh (The Telegraph, London, UK)
'Trick or Treatment? Alternative Medicine on Trial' by Simon Singh and Edzard Ernst (Bantam) is available from Telegraph Books for £14.99 + £1.25 p&p. To order, call 0870 428 4112 or go to books.telegraph.co.uk

Steroid Use Fails To Boost Pregnancy Rates In Infertility Treatments

There is no clear benefit from a hormone commonly prescribed to enhance the effectiveness of infertility treatments, according to a new review of studies. The steroid hormones called glucocorticoids have potent effects on the body's inflammatory and immune responses, so many fertility specialists prescribe them in hopes of making the lining of the uterus more receptive to embryo implantation. But lead review author Carolien Boomsma says that routine practice should stop. "This meta-analysis shows that empirical use of glucocorticoids is not supported by evidence from studies," she said. "Moreover, we don't know enough about the possible adverse effects of glucocorticoids in early pregnancy. Therefore, at present, glucocorticoids should not be prescribed in this way," said Boomsma, a researcher at the University Medical Centre Utrecht in the Netherlands. The review appears in the most recent issue of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic.
The review compares success rates between would-be mothers who took glucocorticoids around the time of embryo implantation and those who did not. All of the women underwent one of two types of assisted reproductive technology. In vitro fertilization (IVF) involves removing mature eggs from a woman's ovary, mixing them with sperm in the laboratory, and placing the embryos in the woman's reproductive tract. Intracytoplasmic sperm injection (ICSI) is another in vitro fertilization practice where a single sperm is injected directly into a harvested egg. The meta-analysis pooled data from 13 studies including 1,759 couples. Every study was a randomized controlled trial, which is considered the most reliable form of scientific evidence.
The review found no overall improvement in pregnancy rates when the assisted reproductive technologies were combined with glucocorticoid treatment. However, six of the studies -- of 650 women undergoing IVF -- revealed a slightly higher pregnancy rate among women who took the hormones. The review authors say the difference barely exceeds that which could be attributed to mere chance.
"At present, glucocorticoids should not be offered as a routine procedure in women undergoing ART (assisted reproductive technologies), except in the context of well-designed studies," the reviewers conclude. Glucocorticoids can bring on problems such as infections or premature births. Though the available studies reported no significant increases in these negative outcomes, they were "poorly and inconsistently reported," the review said. Further research is needed to clarify both benefits and harms, Boomsma and colleagues said. Only three of the studies in the review continued long enough to report actual birth rates rather than simply pregnancy rates. "Trials should be of sufficient duration to have live birth as their primary outcome," the authors say. Despite substantial improvements in IVF and ICSI techniques, only 20 percent to 30 percent of couples go home with a healthy baby after each treatment cycle. That tantalizing hint of benefit may nevertheless encourage some practitioners to continue routine use of glucocorticoids for their IVF patients, said Randall Hines, M.D., director of the division of reproductive endocrinology and infertility at the University of Mississippi Medical Center. "When you have a therapy that doesn't have significant risk and doesn't impose significant burden on the patient in terms of cost or inconvenience, it's hard for people to let go of it," said Hines, who was not involved in the review and does not prescribe glucocorticoids routinely in his practice.

The compiled studies included couples who were infertile due to a wide variety of problems in either the woman, man or both partners. Future research may reveal that glucocorticoids do help specific subsets of these patients, the authors say. For example, women with unexplained infertility, endometriosis, recurrent implantation failure or certain immunological issues may benefit from the hormonal effects on uterine receptivity. None of the studies included in the review focused specifically on these patient groups.

Reference: Boomsma CM, Keay SD, Macklon NS. Peri-implantation glucocorticoid administration for assisted reproductive technology cycles (Review). Cochrane Database of Systematic Reviews 2007, Issue 1.
The Cochrane Collaboration is an international nonprofit, independent organization that produces and disseminates systematic reviews of health care interventions and promotes the search for evidence in the form of clinical trials and other studies of interventions. Visit http://www.cochrane.org for more information.

I fell In Love With This One

A Senior Citizen in Florida bought a brand new Mercedes convertible.
He took off down the road, stepping it up to 80 mph and enjoying the
wind blowing through what little hair he had left on his head. 'This
is great,' he thought as he roared down I-75. He pushed the pedal to
the metal even more. Then he looked in his rear view mirror and saw
a highway patrol trooper behind him, lights flashing and siren blaring.

'I can get away from him with no problem!' thought the man. He
tromped down on the accelerator and flew down the highway at 100mph.
Then 110 mph. Then 120 mph. All of a sudden he thought, 'What am I
doing? I'm too old for this kind of thing.'

He pulled over to the side of the road and waited for the trooper to
catch up with him. The trooper pulled in behind the Mercedes and
walked up to the man. 'Sir,' he said, looking at his watch, 'My shift
ends in 30 minutes and today is Friday. If you can give me a reason
why you were speeding that I've never heard before, I'll let you go.'

The man looked at the trooper and said, 'Years ago my wife ran off
with a Florida State Trooper, and I thought you were bringing her back.'
The trooper replied, 'Sir, have a nice day.'

Visual Humor

I Loved This One

Cancer could return unless stored ovarian tissue undergoes adequate testing before re-implantation

Cancer patients who have been successfully treated for their disease face the prospect of its return if stored ovarian (or testicular) tissue is transplanted back into their bodies without adequate checks, according to researchers at two university hospitals in Israel. Writing in Europe’s leading reproductive medicine journal, Human Reproduction, the researchers say that hundreds of cancer patients worldwide have ovarian tissue and, in some cases, testicular tissue frozen in the hope of being able to have children after their cancer treatment has finished; but they warn that few fertility centres have the skills and use the technology needed to check the tissue for residual cancer cells, making it possible for the original cancer to re-infect the body when the tissue is re-implanted to restore the patients’ fertility.

“The interest in ovarian tissue storage as a real option for preserving fertility in cancer patients has increased. However, genuine concerns regarding the possible recrudescence [re-appearance] of the primary disease following re-implantation of stored ovarian tissue with malignant cells exist,” write the authors. The first author of the report, Dr Dror Meirow, said: “We think it’s vitally important to raise awareness amongst cancer patients, fertility specialists, oncologists and haematologists. There are few fertility centres in the world with the expertise and the technology to run the types of tests on tissue that are needed to detect residual cancer. “However, not every reproductive service that has surgical skills and freezing facilities can be safely responsible for ovarian tissue cryopreservation. We suggest that these centres should store tissue for future investigation, and samples can be shipped to specialist centres for analysis.”

Dr Meirow, who leads the fertility preservation programme in the IVF Unit at Chaim Sheba Medical Center, Tel Hashomer (headed by Professor Jehoshua Dor), carried out the research with Professor Dina Ben Yehuda, director of the Hematology Division at Hadassah University Hospital, Jerusalem. Dr Meirow said that fertility centres with close connections to cancer and haematological centres should be able to work together in order to adopt the correct methods for checking stored tissue.

Before collecting tissue from the 58 young women in this study, Dr Meirow and his colleagues used various imaging methods (sonography, CT and PET scans) to look for cancer in the pelvis and ovaries of the patients; the women were about to receive chemotherapy for haematological cancers such as Hodgkin’s lymphoma, non-Hodgkin’s lymphoma and leukaemia, between 1997 and 2007. They found cancer in the pelvic area of two patients, and therefore ovarian tissue was not harvested. They collected tissue from the other 56 patients and, in addition to freezing strips for future transplantation; they also froze a smaller piece of ovarian tissue separately for each patient. They planned to use these extra strips for future checks for the presence of cancer cells, using the most modern methods that would be available at the time the tissue was thawed and prepared for transplantation.

You are what your mother eats, study

Women who eat cereal for breakfast have an increased chance of having sons instead of daughters, a British study has found. Research by the Universities of Exeter and Oxford have uncovered strong links between higher energy intake among mothers around the time of conception and the birth of boys. "The consumption of breakfast cereals was also strongly associated with having male infants,'' the study said.

The study, published in the Proceedings of the Royal Society B: Biological Sciences journal, focused on 740 first-time mothers in the UK who did not know the gender of their unborn baby. The women were asked to provide records of their eating habits before and during the early stages of pregnancy. They were then split into three groups according to the number of calories consumed per day around the time they conceived.

Of the women in the group with the highest energy intake at conception, 56 per cent had sons, compared with 45 per cent in the group with the lowest calorie intake. As well as consuming more calories, women who had sons were more likely to have eaten a higher quantity and wider range of nutrients, including potassium, calcium and vitamins C, E and B12. The study's lead author, Fiona Mathews of the University of Exeter's School of Biosciences, said the findings could shed light on modern eating habits and birth statistics. "This research may help to explain why in developed countries, where many young women choose to have low calorie diets, the proportion of boys born is falling,'' Dr Mathews said.

While sex is genetically determined by fathers, the study indicated mothers appear able to favour the development of one sex of infant over another. While the mechanism is not yet understood, IVF research shows high levels of glucose encourage the growth and development of male embryos while inhibiting female embryos. Dr Mathews said there were implications for recent debates on whether to regulate so-called gender clinics that allow parents to select the sex of offspring, by manipulating sperm, for non-medical reasons. "Here we have evidence of a natural mechanism that means that women appear to be already controlling the sex of their offspring by their diet,'' she said. In animal studies, scientists have already established that more sons are produced when a mother has plentiful resources or is high ranking. "Potentially, males of most species can father more offspring than females, but this can be strongly influenced by the size or social status of the male, with poor quality males failing to breed at all,'' Dr Mathews said.

"Females, on the other hand, reproduce more consistently. "If a mother has plentiful resources, then it can make sense to invest in producing a son because he is likely to produce more grandchildren than would a daughter. "However, in leaner times having a daughter is a safer bet.''