Reply: RCT of real versus placebo acupuncture in IVF

Abstract

Sir, We refer to the letter by Renckens addressed at our recent publication (So et al., 2009) on the use of acupuncture in IVF treatment, stating that Human Reproduction should not publish papers on absurd forms of treatment such as acupuncture. Although there are no particular comments directed to us, we would like to respond to the opinion stated in the letter and express our views on Traditional Chinese Medicine (TCM) and acupuncture. (i) The WHO booklet on Standard Acupuncture Nomenclature aims to develop a uniform nomenclature in acupuncture so as to achieve global agreement on a standard acupuncture nomenclature. This has greatly facilitated research and exchange of information in this area. However, it should be clarified that the purpose of this booklet is not to correlate the acupoints with the well-known anatomical landmarks in Western Medicine. (ii) Different medical systems may have different developments and philosophies. The theory of Yin-Yang used in TCM is certainly different from that of Western Medicine. Although anatomical correlates of acupoints are still not demonstrated, we should not reject the existence of the acupoints and the effects of TCM in clinical trials. (iii) IVF is not listed as an indication in the WHO report ‘Acupuncture: review and analysis of reports on controlled clinical trials’ because the first randomized study on acupuncture in IVF (Paulus et al., 2002) was published in 2002. Other relevant randomized studies were published in 2006 and several metaanalyses on acupuncture in IVF were published in 2008. There are many meta-analyses on acupuncture in the Cochrane library. (iv) In our paper, we put down the rationale of choosing the acupoints, which is based on the TCM theory. This intends to give the readers more information about Chinese Medicine. In order for the reader to appreciate the effects of acupuncture, we determined outcome measures that are very well defined, scientifically valid and commonly used in studies in Western Medicine. (v) We strongly believe that well-conducted RCT, especially double blind, is still the golden method to examine the effectiveness of a therapy, whether the therapy is believed by some to be absurd or not. We will be delighted to learn any other means which are better to study absurd claims. It is also unfair to say that a therapy is absurd just because it is not consistent with our own beliefs. Science has advanced because scientists have continued to challenge and change some of the established concepts by properly conducted experiments. In the assessment of the efficacy of a therapy, a properly conducted RCT is the best experimental approach to prove or refute the efficacy of a form of therapy. (vi) As the design of studies including those on TCM is evolving and improving, it seems unfair to point out the methodological weakness based on evidence published before 1989. There were also many examples of clinical trials conducted in Western countries with methodological weaknesses. Again, we should always keep the most updated evidence in Science. It is well known that studies with negative results are more difficult to be published than those with positive results. This may be related to the publication policy of journals, rather than where the papers come from. We agree that journals nowadays should not publish papers with serious methodological problems but we strongly disagree that journals do not publish properly conducted RCT on therapies which may appear ‘absurd’ to some readers. Scientific development will be suffocated if journals adopt this approach. We are of the opinion that well-conducted research in TCM should be continued in order to confirm or refute the effectiveness of TCM in clinical practice. The results of these studies, whether positive or not, should be published in peer-reviewed journals. Last but not least, we thank the reader for the comment which is a reminder that we must continue to conduct studies in the highest scientific standard.