The following interview is the first in a series on fertility - causes and cures. Dr. Raymond Chang is the primary force behind the trend toward integrating acupuncture to enhance fertility in contemporary medical practice.
Dr. Chang received his MD degree from Brown University. Among his many accomplishments, he directed the acute care department at Memorial Sloan-Kettering Cancer Center; served on the faculty of medicine at Cornell Medical College, where he developed one of the most complete programs in alternative medicine education; and currently serves on the faculty of the Albert Einstein School of Medicine.
Jennifer Waters (JW): What would you have liked to say in your book, What Your Doctor May NOT Tell You About Getting Pregnant, but did not?
Dr. Raymond Chang (RC): I would have presented the importance of humans (people as creatures of nature) having to comply more with their evolutionary confines in order to achieve health and well-being, including fertility. Many of our modern ailments are due to maladjustment of our ancient bodies to a modern world, and many infertility cases are related to that as well.
JW: How important is one's belief when receiving acupuncture?
RC: It is important. If you believe in something that really doesn't work, it can help; that's the placebo effect. If you don't believe in it, and it doesn't work, it's called the nocebo effect. So, the mind plays an important role. This is the tricky area with acupuncture and the Eastern mind. It is hard to prove how acupuncture works but, we know it works. This is hard for the Western mind to grasp. The patient always asks, "How does it work?" And when I say, "I don't know," they look at me as if to say, "What? You don't even know how it works?" Deep down, we really don't know how it works - but we know it works. The Western mind can't understand that logic. Eastern medicine is not like that. We don't necessarily know exactly how it all works and we don't claim to know, nor do we need to know. We have a theory, but they're theories and we use them to justify what we do, almost an after-the-fact kind of thing. We are able to benefit from acupuncture because we can see the effects without investing in the belief or complete understanding of how it all works.
JW: It's like breathing; we don't believe in it, we just do it. How much do you think the birth control pill has influenced infertility?
RC: Not much. In a social way [it has], but not in a medical way. It may actually help extend a woman's fertile years.
JW: Of all your fertility patients here, how many are doing ART in combination with acupuncture?
RC: Eighty percent. Only 20 percent do only acupuncture and Chinese herbology. Most of our referrals are from doctors at IVF clinics. The average person who comes here has had two failed IVFs and they're looking at their next embryo transfer in about a month.
JW: So, you have a fairly short amount of time to prepare them for the transfer?
RC: Yes, with one month before the transfer, that is still adequate time, but it would be better to have three to four months to get a woman ready with acupuncture and Chinese medicinals.
JW: And how is your response with that short amount of time?
RC: OK. We have about 30 percent to 40 percent success for people who have had two failed IVF cycles. The average age of the woman who comes is 36, so the result is not bad.
JW: Are there any long-term effects from the fertility drugs?
RC: So far, we haven't seen anything major. Long-term? We could only guess. We all wonder, but nothing significant has shown up yet.
JW: Have you found that there are couples that just cannot conceive?
RC: Oh, yeah. There are women whose chances are going to be so bad when their FSH is very high. And then there are some men who have absolutely no sperm. That's a problem.
JW: What would you recommend for a couple to do if they were to choose one thing to increase their fertility?
RC: It's like gambling. If you want to win, you are better off betting multiple hands. You have that much of a better chance of winning that way. So, instead of a sequential approach, try A, then B, then C. If you can place multiple bets at the same time, you waste less time. Also, for our couples, the issue is time. They don't come here when they are 23, but generally 36 years old and up. They cannot try this for six months and then try that for six months. It's people getting married later in life, deferring beginning their family until later in life. This is a social issue. It is not natural for human beings to start to conceive so late in our lives. And it's out of sociocultural reasons.
JW: So, what do you generally recommend for women in that situation?
RC: Lifestyle changes. Acupuncture. I really am not against IVF, although we favor a wholistic and natural approach. It depends on their age and what their circumstances are.
JW: So, lifestyle and advance maternal age seem to be pretty much the main causes of infertility?
RC: Yes.
JW: And what is it about the Western lifestyle that seems to affect one's fertility on such a deep level?
RC: The pervasive stress and busyness of life. Mind affects fertility profoundly. No other species or creatures think or plan their own fertility. Humans are the only ones doing that. It should come naturally, but we try to control it and it can backfire.
JW: And how about supplements? What do you think of royal jelly and L-arginine? Do you recommend them?
RC: Yes, and we recommend a pre-conception vitamin that is mostly L-arginine. It doesn't have the hormonal herbal ingredients like red clover, so the fertility doctors like it.
JW: Let's say a woman has had two failed IVFs and wants to take a break. What's a reasonable amount of time?
RC: It depends on her age and her program. A few months [is OK] if she can afford it.
JW: How about the mind-body relationship?
RC: It's very important and I do tell our patients that it is very important. However, you cannot teach somebody to meditate in a month. What he or she is going through is very stressful. I encourage them to try to stop thinking about it all; find distractions.
JW: Do you use any diagnostic methods other than pulse and tongue?
RC: No. It's been like that for thousands of years now. [We] can't change it.
JW: Do you ever look at location of the uterus as a factor in infertility?
RC: No, because classically it has never been. Chinese medicine is not so interested in anatomy for mainly cultural issues. So, there's never been a focus on that, not that it's not important.
JW: For someone who has a high-risk pregnancy or recurring miscarriage, is there ever a time that you do not do acupuncture in the first trimester?
RC: No, we can always do it. There are textbook approaches for frequent miscarriages.
JW: Do you include herbal medicine in that situation?
RC: No. That is not because they don't work, but because of the legal climate in these United States. We are liable for years and years afterwards. I've been called as an expert witness on cases 10 to 15 years later on claims, for example, that a son or daughter whose autism may be attributable to taking Chinese herbs. On the defense side, we can't come up with anything clearly demonstrating that it's not the herbs. It's indefensible. So, you put yourself in a very indefensible position. We have a very litigious population here. We cannot practice pure medicine based only on what works or not. It is very frustrating, but that is the climate of Chinese medicine in the U.S. at this time.
JW: How do you see the future of Chinese medicine in this country?
RC: On one hand, the increasing recognition and legitimization is great, but on the other hand there is a diminution and vulgarization of true TCM, sort of like the chop suey version of Chinese food. It's not real Chinese food.
JW: Do you find fertility doctors more receptive to Chinese medicine now?
RC: It gives them something to say when things don't work. Instead of saying, "I'm sorry. I have nothing to offer you," they say, "Go try acupuncture." It gives the patients hope and that's very important.
JW: And how much do you adhere to the protocols like pre- and post-transfer?
RC: That is only based on one publication. It's not necessarily true Chinese medicine. It could have happened like that because of the budget of the research study. And I will tell you how these things are decided - an institution comes to say they have $50,000 for this project. So, the statistician comes and says, "We need 80 people, 40 in each group, to show the difference between the two groups - acupuncture versus no acupuncture."
So if the acupuncture sessions are $90 a pop, 40 people in the acupuncture group, $50,000, we have about 14 sessions. That's how you come up with how many sessions in the research. There is one acupuncturist standing by [with] one hour to do pre- and post-IVF transfer treatments. That is the cheapest way to do it. Honestly, in reality, whatever time you come for acupuncture, that's the right time. It doesn't have to be exactly pre- and post-IVF. But when the study came out, it was based on pre- and post-IVF. So, if our next study comes out showing that we used 14 sessions, then everybody says "14 sessions" is the right thing to do. In China, it would be every day. The highest form of protocol is no protocol. So, when you do research and you have to "protocolize" everything; it's a real hassle. It's not going to reflect what acupuncture can really do. These kinds of things I cannot put in the book that I authored. People want to have it laid out in a very linear way, A, B, C, etc., but Chinese medicine is not like that.
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