This is an exploratory multicenter RCT comparing acupuncture with non-treatment. A total of 140 women with POR will be recruited from the following 9 hospitals in China: Shanxi Provincial Hospital of Chinese Medicine, Shandong University Reproductive Hospital, Sun Yat-sen Memorial Hospital of the Sun Yat-sen University, Lanzhou University First Hospital, People's Hospital of Henan Province, Huazhong University of Science and Technology Reproductive Medicine Center of Tongji Medical College, Shanghai Shuguang Hospital, Nanjing General Hospital of Nanjing Military Command, and Luoyang Women and Children Health Care Center. This protocol is in accordance with the principles of the Declaration of Helsinki. It has been approved by the ethics committee of each participating hospital. Written informed consent will be obtained from patients prior to enrolment.
Eligible patients will be randomly assigned to receive acupuncture or non-treatment for 12 weeks, followed by an IVF cycle. Outcomes will be assessed at baseline, after acupuncture or non-treatment intervention, and after the IVF cycle. The flowchart and study design schedule are presented in Figure 1 and Table 1, respectively. This protocol has been registered at Acupuncture-Moxibustion Clinical Trial Registry (AMCTR-IPR-18000198).
This trial plans to recruit 140 women with POR from participating hospitals via poster, network or weChat. The poster will be placed on the bulletin board or other assigned place of hospital. In each participating hospital, at least one staff (usually postgraduate or doctor) will specialize in patient recruitment. Their contact information and clinic for screening visit will be detailed described in the recruitment advertisement.
Participants will be included if they meet the following criteria: (1) diagnosed as POR according to the Bologna criteria published in 2011 by European Society of Human Reproduction and Embryology ; (2) age<40 years; (3) a previous POR (≤3 oocytes retrieved in a conventional stimulation protocol); (4) an abnormal ovarian reserve test (i.e., AFC<5–7 follicles or AMH<0.5–1.1 ng/ml) or two episodes of POR after maximal stimulation; (5) suitable for GnRH antagonist protocol judged by physicians of reproductive medicine; (6) voluntarily join the research and sign the informed consent.
Participants will be excluded with any of the following criteria: (1) history of ovarian surgery, radiotherapy or chemotherapy; (2) repeated miscarriages (including biochemical pregnancy) of more than 2 sessions; (3) repeated implantation failure (experienced at least 3 embryo transfer cycles, or not get clinical pregnancy after cumulatively transferring 10 good quality embryos); (4) uterine malformations (unicornate uterus, bicornuate uterus, uterus didelphys, or untreated uterus septus) and other untreated diseases that can damage endometrial cavity such as adenomyosis, submucous myoma, intrauterine adhesions and scared uterus; (5) abnormal chromosomes of the patient or her husband (except chromosomal polymorphism); (6) untreated hydrosalpinx; (7) patients with contraindications for pregnancy or ART; (8) untreated diseases that can negatively affect pregnancy such as high blood pressure, symptomatic heart disease, diabetes, liver or kidney disease, severe anemia, venous thrombosis, cerebral vascular diseases, and cancer; (9) patients who received acupuncture or moxibustion treatment for POR in the latest 3 months.
Randomization and masking
A block randomization stratified by center will be applied in this trial. Eligible participants will be randomly assigned to acupuncture or non-treatment groups in a 1:1 ratio. The scheme of randomization including any planned restriction (e.g., blocking) will be designed and archived by a statistician who will not be involved in the statistical work of this trial. The allocation sequence will be computer-generated. If a participant is eligible for the trial, the appointed researcher (acupuncturist or reproductive physician) in each center will apply for the random number and group assignment via a telephone- and internet- based central randomization system of the Clinical Evaluation Center of the China Academy of Chinese Medical Sciences. A strict view permission will be set for the central randomization system, which allows no one except the top system administrator to view its randomization scheme. In this study, outcome assessors and data analysts will be blinded to group allocation.
Patients in the acupuncture group will receive a 12-week acupuncture treatment before COH. Acupuncture will be performed by registered acupuncturists with over 2 years’ experience. Hwato brand disposable acupuncture needles (size 0.25 × 25 mm, size 0.25 × 40 mm, and size 0.30×75 mm) and SDZ-Ⅲ electroacupuncture apparatuses (Suzhou Medical Appliance Factory, Suzhou, China) will be used.
The acupuncture protocol designed for this trial is based on our clinical practice for improving ovarian function for women with DOR . It consists of two groups of acupoints. Group 1 (in supine position): GV20 (Baihui), GV24 (Shenting), GB13 (Benshen), CV12 (Zhongwan), ST25 (Tianshu), CV4 (Guanyuan), KI12 (Dahe), EX-CA1 (Zigong), SP6 (Sanyinjiao), KI3 (Taixi), LR3 (Taichong); and group 2 (in prone position): BL23 (Shenshu) and BL33(Zhongliao). These two groups of acupoints will be used alternatively with group 1 as the initial treatment. All acupoints will be located according to the World Health Organization Standardized Acupuncture Points Location . A needle depth of 10 to 20 mm will be applied for GV20, GV24 and GB13 with transverse insertion, and for LR3 with oblique insertion to the direction of KI1 (Yongquan). BL33 will be needled obliquely downward for approximately 60 to 70 mm into the third posterior sacral foramina. The remaining acupoints will be perpendicularly needled for approximately 30 to 40 mm. After insertion, small, equal manipulations of lifting, thrusting or twirling will be performed on all needles (for GV20, GV24 and GB13, twirling only) to reach deqi, a composite of sensations (including soreness, numbness, distention, heaviness, etc) recognized as an essential component for acupuncture effect. In acupuncture with acupoints of group 2, paired electrodes from the electroacupuncture apparatus will be attached transversely to the needle handles at bilateral BL23 and BL33 with a dilatational wave and a current intensity which patients can tolerate (preferably with the skin around the acupoints shivering mildly without pain). Each acupuncture session will last for 20 minutes. Participants will receive 3 sessions of acupuncture per week (ideally every other day) for 12 consecutive weeks, 36 sessions in total.
Participants in the control group will receive non-treatment for 12 weeks before COH.
Participant will start COH with a GnRH antagonist protocol on day 2 or 3 of the menstrual cycle after acupuncture or non-treatment period. GnRH antagonists are commonly used to prevent the premature LH surge which often occurs in poor responders [20,21]. It induces pituitary suppression within a few hours without a flare-up effect, and the suppression is released immediately after their discontinuation . Compared with GnRH agonist, GnRH antagonist protocol shows a shorter treatment time, a lower dosage of Gn and a similar clinical pregnancy rate . In this trial, individualized GnRH antagonist protocol will be administered by physicians of reproductive medicine in each center. Given that participants may become suitable for COH before they complete the 12-week acupuncture or non-treatment, an early termination of acupuncture or non-treatment aiming to seize the opportunity to initiate a COH cycle will be allowed on condition that they complete at least 4-week acupuncture treatment (12 sessions of acupuncture) or non-treatment period.
Permitted and prohibited concomitant treatments
Participants will be discouraged from taking drugs that may interfere with the assessment of acupuncture effect, including Chinese herbs, Chinese patent medicine, sexual hormones, contraceptives, etc. If treatment not recommended in this trial has already been used, relevant information should be recorded in patient’s case report form.
The primary outcome is the number of retrieved oocytes. The secondary outcomes include the assessment of ovarian reserve (AFC and serum levels of AMH, FSH, LH, and E2), other IVF outcomes (fertilization rate, cleavage rate, available embryo rate and high-quality embryo rate) and the score of the self-rating anxiety scale (SAS). Ovarian reserve will be assessed at baseline and after acupuncture or non-treatment period. AFC (via transvaginal ultrasound) and serum levels of FSH, LH and E2 are required to be measured on day 2 to 5 of the menstrual cycle. AMH can be measured on any day of the menstrual cycle. SAS is a self-rating scale for measuring the presence and severity of anxiety . A validated Chinese version of SAS will be used in this trial . It consists of 20 items rated on a 4-point likert scale. When using the scale, participants will be asked to rate each item from 1 to 4 points according to how it applies to them within the past week. The standard score is the sum of the integer part of 1.25 times the raw score (the sum of the 20 items ranging from 20 to 80). The presence of anxiety symptoms is defined as a SAS standard score of greater than 50. A higher score indicates a more serious case of anxiety. SAS will be assessed at baseline and after acupuncture or non-treatment period.
Assessment of safety
Adverse events (AEs) will be obtained by researchers via inquiring participants at each treatment or follow-up visit, or voluntarily reported by participants. Information of AEs will be appropriately documented throughout the trial. Acupuncture-related AEs mainly include intolerable needling pain, bleeding after needle withdrawal, hematoma, local infection, etc. AEs related to COH include pain, organ injury, colporrhagia and infection caused by egg retrieval, ovarian hyperstimulation syndrome, thrombosis, allergy, etc.
Data management and quality control
A pre-trial training will be done for all participating staff on trial protocol, acupuncture manipulation, usage of the central randomization and data management systems, etc. Double data entry will be applied in this trial to ensure the accuracy of data entering. A three-level quality control system (including self-inspection of each center, monitoring by project management group, and auditing by a third party) will be applied to ensure the implementation, record and report of clinical trials conform to the trial protocol, standard operation specifications and relevant laws and regulations. Self-inspection will be done at least once every month by the quality controller of each center. On site or remote monitoring will be done for all centers once every three months by the monitors appointed by the principle investigator. The auditing will be done by Clinical Evaluation Center of the China Academy of Chinese Medical Sciences at the beginning, middle, and end of the trial. Ethics committee will review conduct especially on safety, rights and wellbeing of the participant at the middle and the end of the trial. Regular reminders via WeChat will be used to improve participant compliance. For cases which discontinue or deviate from the protocol, causes and relevant outcome data will be recorded in case report form as much as possible.
Sample size calculation
There are no available clinical studies on the effect of acupuncture for POR. Base on results of a TEAS study on POR , we assumed the mean (SD) number of retrieved oocytes is 4.88 (1.84) in the acupuncture group and 3.95 (1.66) in the control group. A sample size of 57 participants per group will be needed to provide 80% power and a two-sided significance level of 5%. Allowing for a 20% dropout rate, 140 participants will be recruited with 70 participants per group.
Statistical analysis will be performed by a statistician blinded to group assignments using SAS version 9.4 (SAS Institute Inc). All analysis will be based on the intention-to-treat principle. Missing data will be imputed using the multiple imputation method. Continuous data will be presented with mean and standard deviation, or median and interquartile range; categorical data will be presented with number and percentage. Comparisons between groups will be analyzed using the independent t test or wilcoxon rank-sum test for continuous variables, and chi-square test or Fisher exact test for categorical variables. All statistical tests will be two-sided, and p < 0.05 will be considered statistically significant.