Acupuncture for Premature Ovarian Insufficiency: A Randomized, Non-Inferiority Protocol with Exploratory Epigenetics Analysis

Background and Objectives: Premature ovarian insufficiency (POI), characterized by the loss of ovarian function before age 40, significantly impairs reproductive health. While Hormone Replacement Therapy (HRT) remains the standard of care, its efficacy is often limited by incomplete functional restoration and potential adverse effects. Acupuncture has emerged as a promising adjunct; however, robust clinical evidence and a clear mechanistic understanding are currently lacking. This study aims to evaluate the non-inferiority of acupuncture compared to HRT in improving clinical pregnancy rates among women with POI, while concurrently exploring potential epigenetic mechanisms, specifically DNA methylation. Methods: This is a randomized, controlled, non-inferiority trial. A total of 572 participants with POI undergoing assisted reproductive technology (ART) will be recruited and randomized to receive either a standardized acupuncture protocol or HRT (following 2024 ESHRE guidelines). Additionally, 286 women with normal ovarian function undergoing in vitro fertilization and embryo transfer (IVF-ET) for male-factor or tubal infertility will be enrolled as a baseline control group for epigenetic analysis. The primary outcome is the clinical pregnancy rate. Secondary outcomes include serum sex hormones, ovarian reserve markers, ovulation induction parameters, pregnancy outcomes, the Modified Kupperman Index, and DNA methylation profiles in ovarian granulosa cells, characterized via whole-genome bisulfite sequencing (WGBS). Discussion: This protocol is designed to establish clinical evidence regarding the non-inferiority of acupuncture to HRT for POI management. Furthermore, the exploratory epigenetic analysis seeks to elucidate the underlying molecular mechanisms, potentially identifying DNA methylation as a key regulatory pathway.