Syndrome des ovaires polykystiques : évaluation de l'acupuncture

1. Revues systématiques et méta-analyses

1.1. Acupuncture générique

1.1.1. Lim 2016 Ø

Lim CE, Ng RW, Xu K, Cheng NC, Xue CC, Liu JP, Chen N. Acupuncture for polycystic ovarian syndrome. Cochrane Database Syst Rev. 2016. [186498].

Background	Polycystic ovarian syndrome (PCOS) is characterized by the clinical signs of oligo-amenorrhea, infertility and hirsutism. Conventional treatment of PCOS includes a range of oral pharmacological agents, lifestyle changes and surgical modalities. Beta-endorphin presents in the follicular fluid of both normal and polycystic ovaries. It was demonstrated that the beta-endorphin levels in ovarian follicular fluid of otherwise healthy women who were undergoing ovulation were much higher than the levels measured in plasma. Given that acupuncture has an impact on beta-endorphin production, which may affect gonadotropin-releasing hormone (GnRH) secretion, it is postulated that acupuncture may have a role in ovulation induction and fertility.
Objectives	To assess the effectiveness and safety of acupuncture treatment of oligo/anovulatory women with polycystic ovarian syndrome (PCOS).
Methods	SEARCH METHODS: We identified relevant studies from databases including the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, EMBASE, PsycINFO, CNKI and trial registries. The data are current to 19 October 2015. SELECTION CRITERIA: We included randomised controlled trials (RCTs) that studied the efficacy of acupuncture treatment for oligo/anovulatory women with PCOS. We excluded quasi- or pseudo-RCTs. Primary outcomes were live birth and ovulation (primary outcomes), and secondary outcomes were clinical pregnancy, restoration of menstruation, multiple pregnancy, miscarriage and adverse events. We assessed the quality of the evidence using GRADE methods. DATA COLLECTION AND ANALYSIS: Two review authors independently selected the studies, extracted data and assessed risk of bias. We calculated Mantel-Haenszel odds ratios (Ors) and mean difference (MD) and 95% confidence intervals (Cis).
Main Results	We included five RCTs with 413 women. They compared true acupuncture versus sham acupuncture (two RCTs), true acupuncture versus relaxation (one RCT), true acupuncture versus clomiphene (one RCT) and electroacupuncture versus physical exercise (one RCT). Four of the studies were at high risk of bias in at least one domain. No study reported live birth rate. Two studies reported clinical pregnancy and found no evidence of a difference between true acupuncture and sham acupuncture (OR 2.72, 95% CI 0.69 to 10.77, two RCTs, 191 women, very low quality evidence). Three studies reported ovulation. One RCT reported number of women who had three ovulations during three months of treatment but not ovulation rate. One RCT found no evidence of a difference in mean ovulation rate between true and sham acupuncture (MD -0.03, 95% CI -0.14 to 0.08, one RCT, 84 women, very low quality evidence). However, one other RCT reported very low quality evidence to suggest that true acupuncture might be associated with higher ovulation frequency than relaxation (MD 0.35, 95% CI 0.14 to 0.56, one RCT, 28 women). Two studies reported menstrual frequency. One RCT reported true acupuncture reduced days between menstruation more than sham acupuncture (MD 220.35, 95% CI 252.85 to 187.85, 146 women). One RCT reported electroacupuncture increased menstrual frequency more than no intervention (0.37, 95% CI 0.21 to 0.53, 31 women). There was no evidence of a difference between the groups in adverse events. Evidence was very low quality with very wide Cis and very low event rates. Overall evidence was low or very low quality. The main limitations were failure to report important clinical outcomes and very serious imprecision.
Authors' Conclusions	Thus far, only a limited number of RCTs have been reported. At present, there is insufficient evidence to support the use of acupuncture for treatment of ovulation disorders in women with PCOS.

1.1.2. Li 2016 ☆

LI Ruigen, WANG Wei, XU Xiaobei, BU Weijing, WU Zhaoli. [A systematic review and meta-analysis: the efficacy of integrated acupuncture with medicine for the treatment of polycystic ovary syndrome]. Journal of Practical Traditional Chinese Internal Medicine. 2016;1:1-5. [187014].

Background	The efficacy of integrated acupuncture with medicine for the treatment of polycystic ovary syndrome is distinct.
Objective	To evaluate the clinical efficacy and safety of integrated acupuncture with Chinese or western medicine for the treatment of Polycystic ovary syndrome. [Search Strategy] Subject headings combined with free words were used to search in the database of CBM、VIP、CNKI, etc. Retrieval time: from the database built time up to April 2015. The Journal of Chinese Acupuncture &Moxibustion and Clinical Acupuncture and Moxibustion were used as manual retrieval. In addition, the bibliography of the included literatures should be taken into account. [Inclusion Criteria] RCT and quasi- RCT of Chinese literatures. 1 Study object: fulfilling the diagnostic criteria with regardless of age and gender. 2Intervention measures: Treatment group: acupuncture + Chinese medicine or acupuncture + western medicine, Control group: blank control (sham acupuncture or placebo) or conventional therapy with Chinese herbal or western medicine. 3 outcomes: clinical curative effect. [Collection and Analysis of Data] According to the inclusion criteria, 4 researcher independently screened the literatures extracted information and evaluated the risk of bias of all-inclusive studies and cross-checked. Asking the third party for help when disagreement during the overall process. The content of extraction table including: 1) general condition of inclusive studies: authors, cases of experimental and control group, intervention measures, publication data etc. 2) basic features of study object. 3) key element for assessing risk of bias. 4specific details to intervention measures.
Main results	removed 462 papers after reading their theme and summary from the primary 476 papers and did further reading the left 14 papers. Compared to the control group, the overall clinical efficacy of the experimental group was remarkably higher (Z=7. 15, P<0. 00001). As to the pregnancy rate, there Also showed a significantly difference between the two groups (Z=4. 55, P<0. 00001), which suggesting the integrated acupuncture with Chinese herbal or western medicine was superior to the control group.
Problem and Prospect	Due to the quality of the methodology of the inclusion literature is not high, its reliability need to be further demonstrated.

1.1.3. Zhu 2014 ☆

Zhu Yi, Shen Weidong. [Meta-analysis of acupuncture and western medicine in the treatment of polycystic ovarian syndrome]. Journal of Chinese Medicine. 2014;11:1649-165. [186989].

Objective	Use Meta-analysis to compare the therapeutic effect of acupuncture and western medicine in the treatment of polycystic ovarian syndrome.
Methods	Use electronic retrieval of published in the magazine at home and abroad about acupuncture literature for the treatment of polycystic ovary syndrome from 1980 to 2013. In the exclusion of repetition and after a randomized controlled trial, screen into standard randomized controlled trials of acupuncture treatment of polycystic ovary syndrome with the Jadad score evaluating quality evaluation of the literature and Manage 5. 0 software for curative effect evaluation. Use RR value as an index of effect, compared the advantage of acupuncture with western medicine treatment of ovulation disorder infertility and heterogeneity inspection. According to the heterogeneity test results, use fixed or random effects model combined with RR values, P values 95% CI.
Results	In accordance with the inclusion criteria of a randomized controlled with 10 references, a total of 823 patients. Compared acupuncture group with the western medicine group, the relative risk was 1. 54, 95% CI (1. 27, 1. 86), the overall effect inspection Z = 4. 38, P < 0. 000 01, the difference was statistically significant, suggesting acupuncture treatment group was superior to western medicine in control group. Compared acupuncture plus Chinese medicine and western medicine group, combined effect was 1. 48, 95% CI (1. 25, 1. 75), the overall effect inspection Z = 4. 49, P < 0. 000 1, the difference was statistically significant, suggesting acupuncture combined with Chinese medicine treatment was superior to western medicine.
Conclusion	The curative effect of acupuncture treatment in treating polycystic ovary syndrome is superior to western medicine, but the quality of evaluation literature generally is not high, look forward to high quality papers with more sample, randomized controlled method and strict specification.

1.1.4. Ren 2014

Ren LN, Guo LH, Ma WZ, Zhang R. [A Meta-Analysis on Acupuncture Treatment of Polycystic Ovary Syndrome]. Acupuncture Research. 2014;39(3):238-46. 174756

Objectifs	To evaluate the effect and safety of acupuncture treatment of polycystic ovary syndrome (PCOS) by using systematic review in view of evidence-based medicine (EBM).
Méthodes	Original articles about acupuncture treatment of PCOS published from the database-established year to November of 2013 were searched from the Chinese National Knowledge Infrastructure Database (CNKI), Chongqing VIP Chinese Science and Technology Periodical Database (VIP), Chinese Biomedical Library (CBM), Wanfang Data, PubMed, and the Cochrane Library and the associated references-indicated papers by using keywords of polycystic ovary syndrome, randomization, acupoint, acupuncture, acupuncture plus moxibustion, acupuncture plus acupoint-embedment of catgut, and acupuncture plus otopoint application. Those articles about treatment of PCOS with simple abdominal acupuncture, simple acupoint-embedment of catgut, simple otopoint-pellet-pressure, and simple moxibustion treatment, and simple abstracts were excluded. If the articles re-published in both Chinese and English and in academic conferences and journals, one of them with higher quality was included. Two independent reviewers extracted data from located articles in a pre-defined structured way, and the Meta-analysis was conducted using software RevMan 5.2, otherwise using the qualitative analysis.
Résultats	A total of 31 articles (28 in Chinese, 3 in English) containing 2,321 cases of PCOS patients met the included criteria. Meta-analysis showed that the clinical efficacy of simple acupuncture was the same as that of western medicine, and the efficacy of acupuncture combined with Chinese herbal medicine interventions was obviously higher than that of western medicine (P < 0.05). In addition, simple acupuncture intervention and acupuncture combined with Chinese herbal medicines or with moxibustion treatment have advantages in reducing serum luteinizing hormone/follicle-stimulating hormone (LH/FSH), insulin resistance (IR), testosterone (T), and body mass index (BMI). However, the quality of the collected articles is generally lower due to unclear bias, no sample quantity estimation, incorrect randomization methods, no follow-up survey, etc.
Conclusion	Acupuncture therapy may be effective for PCOS, but needs to be confirmed further by larger sample randomized controlled trials.

1.1.5. Lim 2011 Ø

Lim DC, Chen W, Cheng LN, Xue CC, Wong FW, O'Sullivan AJ, Liu JP. Acupuncture for polycystic ovarian syndrome, Cochrane Database Syst Rev. 2011. [160670].

Background	Polycystic ovarian syndrome (PCOS) is characterised by the clinical signs of oligo-amenorrhoea (infrequent or very light menstruation), infertility (failure to conceive), and hirsutism (excessive hair growth). Whilst Aleem 1987 revealed the presence of beta-endorphin in the follicular fluid of both normal and polycystic ovaries, Petraglia 1987 demonstrated that the beta-endorphin levels in ovarian follicular fluid of otherwise healthy women who were undergoing ovulation were much higher than the levels measured in plasma. Given that acupuncture has an impact on beta-endorphin production, which may affect gonadotropin-releasing hormone (GnRH) secretion, it is postulated that acupuncture may have a role in ovulation induction and fertility.
Objectives	To assess the efficacy and safety of acupuncture treatment for women with polycystic ovarian syndrome (PCOS).
Methods	Search strategy: Relevant studies were identified from the Menstrual Disorders and Subfertility Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), Ovid MEDLINE® In-Process and other non-indexed citations, Ovid MEDLINE® Daily and Ovid MEDLINE(R), EMBASE, PsycINFO, AMED, Chinese National Knowledge Infrastructure (CNKI) (including the Chinese journal full-text database (CJFD)), Chinese BioMedical Literature Database (CBM), VIP database for Chinese Technical Periodicals, China's important Conference Papers Database, and the China dissertation database. Selection criteria: Truly randomised controlled trials (RCTs) that studied the efficacy of acupuncture treatment for infertility in women with PCOS. We excluded quasi- or pseudo-RCTs. Data collection and analysis: We aimed to extract data independently by three authors using a piloted data extraction form. Data on study characteristics including methods, participants, interventions, and outcomes would be extracted. Crossover trials were not included unless there were first-phase data provided. Non-randomised controlled studies have been excluded.
Main results	No truly randomised controlled trials of acupuncture for PCOS were found.
Authors' conclusions	The current conventional medical treatments for women with PCOS are prescription medications, surgery, and lifestyle changes. Associated problems with current western therapies are the cost, risk of multiple pregnancies, undesirable side effects, and inconsistent effectiveness. Non-randomised acupuncture studies in PCOS have suggested a low associated adverse events rate, no increased risk of multiple pregnancies, and that it is inexpensive. However, there no RCTs have been performed in this area thus far. Therefore, properly designed RCTs are required before a conclusive statement can be drawn to support the use of acupuncture in the management of PCOS.

1.1.6. Lim 2010

Lim CE, Wong WS. Current evidence of acupuncture on polycystic ovarian syndrome. Gynecol Endocrinol. 2010;16:. [155287].

Objective. This paper aims to provide a literature review on evaluating the efficacy of acupuncture therapy in the treatment of polycystic ovarian syndrome (PCOS) by reviewing clinical trials; randomised and non-randomised and observational studies on PCOS. The paper will also determine the possible mechanism of acupuncture treatment in PCOS, limitations of recruited studies and suggest further improvements in future studies. Design. A comprehensive literature search was conducted through the databases Medline, PubMed, EMBASE, Cochrane, AMED (Allied and Complementary Medicine), NCCAM (The National Centre for Complementary and Alternative Medicine) to identify relevant monographs. Results. Four studies were recruited. Several studies showed that acupuncture significantly increases beta-endorphin levels for periods up to 24 h and may have regulatory effect on FSH, LH and androgen. beta-endorphin increased levels secondary to acupuncture affects the hyperthalamic-pituitary-adrenal (HPA) axis through promoting the release of ACTH through stimulation of its precursor pro-opiomelanocortin synthesis. Inclusion criteria. All available acupuncture studies on human subjects with PCOS from June 1970 to June 2009. Exclusion criteria. Studies not meeting the inclusion criteria, published in languages other than English or animal studies. ^Conclusion. Acupuncture is a safe and effective treatment to PCOS as the adverse effects of pharmacologic interventions are not expected by women with PCOS. Acupuncture therapy may have a role in PCOS by: increasing of blood flow to the ovaries, reducing of ovarian volume and the number of ovarian cysts, controlling hyperglycaemia through increasing insulin sensitivity and decreasing blood glucose and insulin levels, reducing cortisol levels and assisting in weight loss and anorexia. However, well-designed, randomised controlled trials are needed to elucidate the true effect of acupuncture on PCOS.

1.2. Critères d'évaluation particuliers

1.2.1. Fécondation in Vitro

Voir l'article correspondant

2. Recommandation de bonne pratique

2.1. World Health Organization (WHO) 2016

Balen AH, Morley LC, Misso M, Franks S, Legro RS, Wijeyaratne CN, Stener-Victorin E, Fauser BC, Norman RJ, Teede H. The management of anovulatory infertility in women with polycystic ovary syndrome: an analysis of the evidence to support the development of global WHO guidance. Hum Reprod Update. 2016. [187945].

There is no clear evidence for efficacy of acupuncture or herbal mixtures in women with PCOS

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