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Acupuncture and Sham Acupuncture for Pain Relief.

In Reply Ms Szmelskyj and Mr Szmelskyj question the rationale for increasing ovarian blood flow in women with PCOS, which conflicts with previous work.1 Electroacupuncture stimulation, independent of frequency, activates sympathetic nerve fibers innervating the ovaries during stimulation, an effect that is mediated via the central nervous system.2 The rationale for using low-frequency and not high-frequency electroacupuncture was because repeated low-frequency electroacupuncture treatment decreases sympathetic nerve activity and circulating testosterone and induces ovulation in women with PCOS.2 In our trial, we did not measure ovarian blood flow response to treatment, but there is no evidence of a link between ovarian blood flow response and live birth in women with PCOS. Therefore, we disagree with Szmelskyj and Szmelskyj, who suggest that low-frequency electroacupuncture in women with PCOS might be detrimental as they are at increased risk of developing OHSS, possibly due to high ovarian blood flow. Of note, we did not observe an increase in OHSS in the active acupuncture group. Hence, our data did not indicate that low-frequency electroacupuncture had an adverse effect on OHSS. We disagree with the rationale that future research should consider comparing lowwith highfrequency electroacupuncture because this frequency has not been shown to affect fertility. We agree with Dr Li that the control acupuncture procedure in our trial was not a negative control but rather an active treatment. However, we disagree that a no-acupuncture control group is needed in future trials. Rather, we suggest that future studies should be designed as comparative effectiveness trials that do not involve control acupuncture, because there are no inert acupuncture controls. We found no difference between active acupuncture with combined manual and low-frequency electrical stimulation with deep needle placement and control acupuncture with superficial needle placement without any stimulation. Therefore, if there is an effect of acupuncture, it is nonspecific and not related to number of needles, their placement, or stimulation. With our rigorous study design, well-defined hypothesis, and large cohort, the appropriate conclusion is that clomiphene is superior to acupuncture for live births in infertile women with PCOS. Both acupuncture and control acupuncture groups had ovulation and live birth rates higher than what has been reported for patients who received metformin only3 or no treatment. To investigate whether acupuncture has a higher live birth rate than, for example, metformin requires a head-to-head comparison without control acupuncture. Our trial indicates that acupuncture is not a substitute for clomiphene for infertility in PCOS, although why and how acupuncture may work require further study.4