Page 59 - PCC14

exclusion criteria. Protocols and results of the studies were examined according to specific inclusion criteria. Only studies that met the inclusion criteria were assessed in the final anal- ysis. Studies were eligible if they met one of the following criteria: level I or II studies that assessed the effectiveness of a procedure correlated with an outcome measure (pregnancy, implantation, or live-birth rates); meta-analyses; and rele- vant articles from bibliographies of identified articles. This guideline focuses principally on pregnancy rate since most of the studies report pregnancy rates rather than live-birth rates.
Three members of an independent task force reviewed the full articles of all citations that possibly matched the prede- fined selection criteria. Final inclusion or exclusion decisions were made on examination of the articles in full. Disagree- ments about inclusion among reviewers were discussed and solved by consensus or arbitration after consultation with an independent reviewer/epidemiologist.
The quality of the evidence was evaluated using the following grading system and is assigned for each reference in the bibliography:
Level I: Evidence obtained from at least one properly de- signed randomized, controlled trial.
Level II-1: Evidence obtained from well-designed controlled trials without randomization.
Level II-2: Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group.
Level II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in un- controlled trials might also be regarded as this type of evidence.
Level III: Opinions of respected authorities based on clin- ical experience, descriptive studies, or reports of expert committees.
Systematic reviews/meta-analyses were individually considered and included if they followed a strict methodolog- ical process and assessed relevant evidence.
The strength of the evidence was evaluated as follows:
Grade A: There is good evidence to support the recom- mendation, either for or against.
Grade B: There is fair evidence to support the recommen- dation, either for or against.
Grade C: There is insufficient evidence to support the recommendation, either for or against.
Number of studies identified in electronic search and from examination of reference lists from primary and review arti- cles: 2,086. Number of studies included: 143.
Summary of Inclusion/Exclusion Criteria
When current meta-analyses were not available to combine existing data, selected meta-analyses of studies were per- formed by the American Society for Reproductive Medicine
(ASRM) Practice Committee to estimate the pooled relative risk (RR) ratios of outcomes of interest. Statistical analyses and construction of forest and funnel plots were performed with Stata version 12.1. RR ratios, and 95% confidence inter- vals (CIs) were calculated for each outcome. Random effects models were used for the meta-analyses. Heterogeneity was as- sessed with the use of the I2 test. Publication bias was assessed by constructing funnel plots. Tables listing inclusion/exclusion criteria are available online as Supplemental Material.
CLINICAL PRACTICE
Is Patient Preparation, including Acupuncture, Relaxant, Sedation, or Antibiotics, before Embryo Transfer Necessary and Does It Affect Pregnancy and Live-birth Rates?
Over the past two decades there has been significant interest in maximizing assisted reproductive technology (ART) preg- nancy rates through enhancing patient preparation prior to embryo transfer. These attempts have included acupuncture, analgesics, anesthesia, massage, transcutaneous electrical acupoint stimulation (TEAS), whole-systems traditional Chi- nese medicine (WS-TCM), and prophylactic antibiotics. These interventions provide theoretical benefits, which include modulating hormones, altering energy flow throughout the body, enhancing blood flow to the uterus, reducing stress, and reducing microbial colonization of the genital tract.
Acupuncture. Acupuncture has been the focus of significant interest and research, as it is an important tradition in Chinese medicine that dates back over 3,000 years. Acupuncture in- volves the insertion of fine needles through the skin intended to alter the flow of energy throughout the body. There are a variety of different acupuncture protocols based upon the un- derlying diagnosis. Protocols can include varying acupunc- ture points and treatment intervals during ovarian stimulation, retrieval, and before and after transfer.
A review of the medical literature is challenging as there is no consensus regarding a particular acupuncture protocol, and studies vary in regard to their inclusion and exclusion criteria, investigator blinding, and treatment of the control groups, including sham acupuncture.
A number of randomized controlled trials (RCTs) on acupuncture have been published with contradictory results. There are five RCTs showing some benefit of acupuncture (5–9). Anxiety levels were lower (P<.05) and clinical pregnancy, implantation, and live-birth rates were higher (P<.017) in the auricular acupuncture groups vs the sham auricular acupuncture and control groups in the largest of the trials, which included 305 IVF patients (7). In another trial of 273 women treated with IVF-intracytoplasmic sperm injection (ICSI), the treatment group received acupuncture on the day of embryo transfer and had a clinical pregnancy rate of 39% compared with a control group that had no acupunc- ture 24% (P1⁄4.038) (9). A meta-analysis of seven trials and 1,366 patients also showed an improved clinical pregnancy rate (odds ratio [OR] 1.65, 95% CI 1.27–2.14; seven trials) and live-birth rate (OR 1.91, CI 1.39–2.64; four trials) when acupuncture was given with embryo transfer (10).
Page 52 of 69
VOL. 107 NO. 4 / APRIL 2017 883
Fertility and Sterility®
PRECONGRESS COURSE 14 I BARCELONA, SPAIN – 1 JULY 2018 59