The following is an interview with Dr. Diane Cridennda, leading specialist in the integrative field of fertility and TCM. I had the opportunity to meet with her in her office in Colorado Springs, Colo.
Thank you, Diane, for your cutting-edge work in this field!
Jennifer Waters (JW): Please tell us about your background and how you came to get involved with fertility as a specialization.
Diane Cridennda (DC): I graduated from radiology technology school in 1974. I worked as a radiological technologist until 1995. I had become ill, and Western medicine was unable to help me. I was a competitive triathlete and had become so ill that I could not walk up a flight of stairs to get to my bedroom. My thyroid gland had become hyperactive and my liver enzymes were dangerously elevated; this virus was killing my bone marrow cells. I spent a few months in bed. Western medicine diagnosed me with chronic fatigue, for lack of a better term. I saw the limitations of Western treatment and turned to TCM. Within one and-a-half years of acupuncture, I was off all medication, including thyroid medication, and was back competing in triathlons. At this point, I decided to have a career change.
I studied at the International Institute of Chinese Medicine in Santa Fe, N.M., where 95 percent of my teachers were from China. I then spent a summer in Beijing, where I saw this ancient medicine being used firsthand.
I think because I was first affiliated with Western medicine and TCM later, I saw the benefits of combining both. I had also seen so many people fall through the cracks of Western medicine that it scared me; I thought, "That could have been me."
After I graduated from acupuncture school, I started my practice in Colorado Springs. I was so keen to begin working with athletes (the Olympic Training Center is here), but I soon discovered that athletes spend all their money on training and racing and not taking care of themselves. The infertility piece just fell into my lap.
JW: What do you think is the best way to promote fertility?
DC: Education is the key. With accurate information, couples can make educated decisions. There would be a lot less wasted time and money if they understood what tests and treatments are available to them.
Each month, I present at a free seminar called "In Search of the Stork." It is given by Paul C. Magarelli, MD, PhD, a board-certified reproductive endocrinologist & infertility specialist (RE&I) of Reproductive Medicine and Fertility Centers (RMFC). Couples come to get accurate information on both high-tech and low-tech infertility treatments. I talk about TCM, and we give the audience facts and data and show them the impact of acupuncture combined with IVF. I present data from my years of scientific research that has been published in both Western and Eastern journals. It is amazing to most of the audience that an acupuncturist and RE&I specialist worked so closely together. Our data, plus other randomized controlled trials (RCTs), demonstrated that acupuncture combined with IVF improves outcomes by an average of 15 percent. This converts to 1.5 couples in every 10 who will not have to repeat an IVF cycle to create a family. For example, using the current 150,000 IVF cycles performed in the U.S. (CDC), if we reduce the number of cycles needed by 15 percent, then the savings would be $150,000,000 per year ($10,000 per cycle x 15,000 cycles saved). This is huge!
JW: What have you learned through your years of clinical work about fertility?
DC: I have seen the emotional roller coaster these couples go through. It can be devastating and very hard on relationships, not just between the couple, but also with family and friends. When these couples see everyone around them having babies, it becomes a real problem. I also see loving couples lose it when they are unable to conceive. Instead of waking each morning turning to each other for hugs, they reach for the thermometer. They often forget about the love and the juice (yin), making love a planned event - timed at best!
I have also learned how important it is for these couples to be seen by a board-certified reproductive endocrinologist and infertility specialist (See www.socrei.org). I see OB/GYNs prescribing Clomid (clomiphene citrate, a commonly used fertility drug) for months at a time, unmonitored. That can't be good. This is where the education comes in.
JW: How is this different from all of your research?
DC: Well, the research has been pretty amazing. We are currently investigating the role acupuncture can play in male-factor infertility, reducing recurrent pregnancy loss and moderating the ill effects of ovarian hyperstimulation syndrome.
I also work with couples who choose not to do IVF. I have had some amazing results - babies born to these women who were turned away from some Western practitioners! I have faith in our ancient medicine, but also have become realistic about our limitations.
In all cases, we are seeking harmony of the body, whether through nature or through Western medications modulated with acupuncture, which is a must to offset side effects of the Western medications.
JW: Please tell us about your research and where we can find it published.
DC: Dr. Magarelli and I have been conducting research for six years now, and we have over 815 patients in our database. We collect data on over 200 separate factors that may impact IVF outcomes. We are self-funded, which has been very challenging. We are not associated with a university; rather, we work in private practice. It has been hard work, but worth every bit of our effort. Dr. Magarelli and RMFC have some of the highest pregnancy rates in the country and I, for one, believe this is a direct result of the fact that over 85 percent of his IVF patients utilize acupuncture as part of their treatment.
Our abstracts have been published in the Fertility and Sterility supplements associated with the American Society for Reproductive Medicine (ASRM), as well as the Pacific Coast Reproductive Society (PCRS). In fact, we are really bridging East and West this year by offering seminars on acupuncture and infertility at the April 2008 PCRS seminar in Rancho Mirage, Calif. Our research has been highlighted at the Medical Acupuncture Society annual meetings, the AARC society of England and at specialized acupuncture seminars in Vancouver. We will be featured speakers at the Greater Los Angeles Resolve meeting in 2007. We have presented our research in London and Canada, and traveled to Venice to present our research at the World Congress for Human Reproduction.
JW: Do you feel that any woman with a diagnosis of "infertility" can achieve a "take-home baby"?
DC: I like the term "take-home baby" (THB). This is what our research really focuses on. Our goal is not just pregnancy but a baby! Our studies demonstrate fewer miscarriages, fewer ectopics, as well as fewer multiples, which translates to more THB.
I think there are some cases where achieving a baby is just not going to happen. However, we are a society of "hurry up." Often, couples are just not willing to spend the time, money and effort to make some major changes in their lives. Using TCM can be incredibly effective in helping them achieve a baby. They have to be patient and give it time. One of my goals is to work with these couples who are going through IVF for at least three to four months before going into a cycle. I think we can improve outcomes even more. I recently created our C.A.R.E. package for infertility treatments. We reduced our fees to ensure our patients get the requisite 11 cycles, which we have demonstrated are needed for optimal acupuncture effects.
I also believe that many couples would not achieve a family without high-tech fertility treatments. In the case of vasectomy or failed vasectomy reversal, TESA can be used to collect the sperm. This is a procedure where the sperm is extracted surgically and used to fertilize the egg. When a patient comes to me for treatment of infertility, I ask them four basic questions: 1) Are there eggs?; 2) Is there sperm?; 3) Can the egg and sperm meet?; and 4) Is there a safe place for the baby to grow? If there is one factor missing in this combination, we have to look seriously at getting some help from the RE&I. This is not to say that TCM cannot help. I believe that by combining the two modalities, the couple can increase the ability to create a family.
JW: What should be required of any LAc who wants to specialize in fertility?
DC: There are excellent courses available. I had the honor of co-presenting with Jane Littleton, and her course is stellar. She is incredibly knowledgeable about all aspects of not only TCM but Western fertility treatment and human biology. I would recommend her books and her courses. There are many more to highlight as well.
It is imperative to know the biology of reproduction, as well as TCM differentiation of syndromes. LAcs must team with an RE&I and create a bridge of knowledge. Both worlds are needed for a successful family to be created, especially with high-tech infertility treatments.
It is imperative to continue to study and take courses to expand our knowledge. Most of the Western knowledge will come from Western textbooks, as well as postgraduate courses that are designed for physicians in the field of infertility. I have learned a lot just from working so closely with an RE&I. It becomes a second language after a while. Most Western diagnosis can be "translated," so to speak, into Chinese terms and will provide me clues as to treatment plans based on Eastern and Western terms.
I am a member of the American Board of Oriental Reproductive Medicine and, as you may know, we are in the process of creating a specialization exam that will allow our Western colleagues a better sense of the training and competency of the acupuncturists that they refer their patients to.
Dr. Magarelli was very clear with me when I initially went to talk to him about how I thought acupuncture could improve his outcomes. At our first meeting, he basically said: "Show me the data," "Prove it does not hurt," and "Show me it works!" I did show him (based on our research) that it doesn't harm patients. It does work!
JW: This area of medicine has become quite cutting-edge in terms of the integrative approach being adopted by more and more MDs and fertility clinics around the country. Can you share with us your experience working directly with high-tech fertility clinics?
DC: This part has been a challenge as well. Due to my Western background, I was able to communicate with the RE&Is in their language! It has taken me a long time to learn the lingo and the procedures. When I first started treating IUIs with the modified Paulus protocol, I was using the same timing as the IVF patients until I realized that, in fact, the embryo from IVF will implant within 24 to 48 hours. With an IUI, it is three to five days, so I had to time my treatments differently. This is where learning the biology of reproduction is a must.
East Winds Acupuncture works with RE&Is from around the globe, and we have succeeded in creating a liaison by approaching them with real data. I have many practitioners say to me, "Tell me how to get my foot in the door of the RE&I." I tell them to put a package together of our research, as well as the recent published data. Today, you can go to my Web site (www.eastwindsacupuncture.com) and download the graphs and tables. It gives a list of over 15 publications demonstrating efficacy and discussing ways to share the care of patients. Research is the Achilles' heel. All of their treatments are based on scientific facts - we need to give them scientific facts about TCM.
I also created an Acupuncture Consortium with acupuncturists from Colorado, New Mexico and California, working 24/7 to provide coverage for IVF centers. This really impressed Dr. Magarelli. It is our recognition that health care is not Monday through Friday, 8 a.m. to 5 p.m., but every day, 24/7.
JW: Do you see this integrative approach to health care and fertility happening much more internationally, and the USA is finally catching up?
DC: I do know that many of the RCTs have come out of Europe, mostly from universities. I also know that in the U.K., the NHS (National Health Service) has accepted acupuncture as standard of care and it is paid for by the government. For years, Germany has been using complementary modalities for all health care. I think we have a long way to go, but I feel research in this field is making an impact on our credibility. What East Winds Acupuncture and RMFC have done is to push acupuncture into the spotlight. Our research lends legitimacy to the integration of our health care modalities. The U.S. can feel proud about what this intertwining of practices has done for couples seeking a family.
JW: Do you feel that TCM is becoming "watered down" due to the limitations set forth by the fertility doctors not wanting their patients to take herbs, for example?
DC: Yes, I do. The biggest problem is that there are no studies published dealing with this. I think most RE&Is have become convinced that acupuncture can't harm their patients, but they are much more likely to forbid the use of herbs. I think the herbs are very important. The medications have side effects, and we can really help that with herbs.
Another factor is that we have had to conduct our research using the Western model; it seems this is the only way to get our foot in the door. One journal criticized our research because our protocol used "too many acupuncture points!" Yet we have had to conduct this research to satisfy the Western world. It is difficult. However, we had fabulous results with the protocol that we did use. Imagine if we used our treatments according to TCM. Wow, the results would be far superior! We just need to show them the data.
Another concern I have is that most RE&Is ask for "that protocol" for their IVF patients, rather than asking for a consult from a TCM practitioner as to what will most help. The illusion is that it is simply a cookbook approach for the treatment of infertility. This can and will be overcome as we migrate more and more of our knowledge to Western style research and "convince" some far-sighted RE&Is that TCM is a mature, proven field of medicine that should be used to its fullest to create families for their patients. You can imagine a surgeon attempting to remove a fibroid with one hand tied behind his back. Dr. Magarelli already allows me to add herbs for some patients and certain maladies - it is a start!
JW: I know you are on the board of the American Board of Oriental Reproductive Medicine, which has created a test for licensure for the specialization of fertility. Can you share with us why you think this is necessary?
DC: In fact, taking this exam is not a requirement, but it follows the trend for specialty boards that has been set up in other fields of TCM, such as sports medicine. Our goal is simple: higher standards of patient care as well as gaining the confidence of REIs.
If I needed infertility treatments, my choice would be a board-certified RE&I because I know they have had specific training over and above that of an OB/GYN or family practitioner, and that they would give me the best, most current care.
JW: There is a lot of controversy over this concern about a self-appointed board and that it seems unnecessary to create a specialization within a medicine that treats patterns, not disease. What is your opinion on this?
DC: This "self-appointed" board, consisting of volunteers, was selected based upon a number of criteria: years of experience in the field of infertility, published research, authorship, as well as degrees such as a PhD or DAOM. I was invited to be on the board, based on my involvement in research. If acupuncturists are going to work side by side with the RE&Is, there is a level of competency, both Western as well as TCM, that should be demonstrated. Yes, there is a lot of controversy over this and we are hopeful that with constructive communication, this will be resolved. It was not intended to threaten anyone, just to provide the best care for the patients.
I have seen some RE&Is offer acupuncture in their office. I feel this takes away from what the patient really needs. A few years back, Dr. Magarelli created the Integrative Health Institute for Women's Care. I was the acupuncturist that worked within his clinic. It was well-appointed, private and had very nice working conditions, but I felt (as did he later agree) that the patients needed a break from the MD environment to maximize their healing. Specifically, they need to feel like they are getting a break from the medical side of an IVF cycle. The setting of an acupuncture clinic is going to offer them a safe haven, and we as practitioners can offer a nurturing environment.
I have realized the rigor it takes to do research. I hear many TCM clinics quote their success rate for pregnancies. I always think about how many parameters we actually looked at in our research (over 200!), so we were sure to compare similar patient profiles. We didn't simply take only one or two patients and say, "Wow, both got pregnant, so 100 percent were helped!"
One example is: We looked at the low responders and matched them for FSH, age, BMI, male factor and years of trying to conceive, to name a few. We compared the acupuncture group with the non-acupuncture group. What we found was the acupuncture group achieved 17 percent more pregnancies than the non-acupuncture group. Remarkably, the rate of babies for couples in the acupuncture group was 70 percent higher. What was even more amazing was that we saw 20 percent more THB in the acupuncture group, compared to the control (average responders).
These studies were designed to use a protocol of acupuncture points and not TCM diagnosis. This was necessary to fit the Western model and rigor of science. I think we can do even better using TCM, combining the use of herbs as well as differentiation of syndrome. I just don't know where the money is for research and how many private practice acupuncturists have the time, money or desire to pursue this.
I feel we have come a long way to earn credibility in our field, but it is not without a cost.
Click here for previous articles by Jennifer Waters, LAc, Dipl. Ac.