Hear from Dr. Marc Sklar, a Harvard-trained practitioner, Doctor of Acupuncture and Oriental Medicine, author and president of the American Board of Oriental Reproductive Medicine. He is the creator of Fertility TV, MarcSklar.com and ReproductiveWellness.com, and the co-author of Secret of Conception. They discuss the often unknown scope of Oriental medicine, including acupuncture, and its many applications to improve women's health.
Get answers to questions like, "what tests should I ask my doctor for?" and "is acupuncture an ongoing or short-term treatment?"
Georgie: welcome! Tell us about yourself.
Marc: I am a doctor of Chinese Medicine and the sitting president of the American Board of Oriental Reproductive Medicine (ABORM). I’m a fertility specialist practicing in San Diego but I work with patients all over the world. I’ve been doing this for about 18 years. Fertility and reproductive health is really a passion of mine. It has been for quite some time. From about 20 years ago, when I got into this specialty, it became a love of mine since the first patient I ever helped get pregnant. It’s so impactful and so beautiful to be able to help a couple or an individual be able to have a child and have a family.
Georgie: what is your role as the president of the board?
Marc: The ABORM is a specialty board within the profession of Chinese medicine that certifies members who have a minimum competency in understanding reproductive health and facility. This board was created by a good friend of mine who unfortunately passed away several years ago. It was a passion of his to create this board for the public good. What we have seen is that everybody who would graduate from school with no more than a day of practice could say, I’m a fertility specialist and hang their shingle and the public would not know any better.
With any speciality, there are a lot of intricacies and details within the speciality of reproductive health and fertility. If you don’t have true knowledge and experience within this field, you won’t be able to manage patients properly. At a very basic level, you’ll be able to take care of patients, but once they start getting more complex, once they’ve been on the fertility journey for longer and going through an assisted technique if you need to look at hormone testing and work with the IVF/IUI world, there is a LOT for a professional to know and understand.
The goal, when the organization was created, was to make sure that those providers who were certified by us had a minimum competency and understanding. When a couple or individual went to see them for their fertility needs, our process ensured that a provider was able to treat them. The board has been around for 12-13 years. We have about 450 members. There are groups of examinees. Everyone has sat for a six-hour test. Our members have to pass that exam and then maintain credentials with us annually through continuing education.
This is a unique and special group of individuals. I’m constantly amazed by the individuals who are a part of this organization. They have leadership, knowledge and ability to work well with patients and the fertility world at large.
For anyone who is out there and looking to work with an acupuncturist, first and foremost they should see if there is an ABORM fellow in their area. That’s as simple as going to the website (ABORM.org) and searching by zip code.
Georgie: I know in my journey I saw several acupuncturists and received a variety of treatments. I was never sure whether it was right or not.
I’d love to better understand how an acupuncturist can support women.
Marc: it’s important to get on the same page. In the U.S., when we talk about acupuncturists, we think of “Chinese medical doctors.” In China, acupuncturists are just doctors. For the most part, in the U.S., if you are an acupuncturist, you actually are a Chinese medicine doctor. They have an understanding of your body both from a Western and Eastern medicine perspective. This gives them many tools in their belt aside from just therapy or treatment through acupuncture. That’s just one tool. Chinese herbs, cupping, dietary recommendations, lifestyle recommendations: there’s a whole gamut of therapies that we have at our disposal and can use at any given time for any patient.
The term “acupuncturist” has been meant to mean more in the United States but I just wanted to clarify that from the onset.
When it comes to what we can do for fertility, there are many things. We do separate and think about acupuncture and Chinese herbs differently. When we want to affect someone internally, change the constitution or environment of the body, we often think about herbs.
Let’s talk about egg quality for a moment. If we want to improve egg quality in a fertility patient, acupuncture is probably not the top tool we would use. We’re trying to change something at a cellular level: the cells of a follicle a woman is producing. For that, we need to ingest something. That’s where herbs come in. We create Chinese herbal formulas specifically for an individual patient’s constitution. That, over time, is changing the chemical structure of the body.
When I think about acupuncture, it’s not that it can’t affect egg quality but it does it in a different way. Acupuncture does two main things for fertility:
Increase blood circulation: dilates blood vessels and increases the amount of blood circulating through the body. Point prescriptions direct blood to specific parts of the body (the ovaries, the uterus, etc.). This brings more nutrients, supporting quality.
Regulating the nervous system: stress is a big part of our medical world. Stress compromises our nervous system. Stress makes any medical condition worse.
For instance, the hypothalamus and pituitary systems have a huge impact on your body. Stress negatively impacts things like thyroid function, which has an influence on fertility. Over time, stress negatively impacts ovaries and testicles. Decreasing stress improves health. Acupuncture also supports the regulation of hormones and helps with egg quality.
There are a lot of things we can do with Chinese medicine that influence fertility overall.
Georgie: let’s talk about stress. One thing I heard after interviewing a reproductive endocrinologist was that stress doesn’t impact fertility. I don’t see that in real life. Stress appears to be a factor almost universally. Second, a lot of women in the infertility world say “well, during wartime, fertility rates weren’t impacted, so you can easily get pregnant under stress.”
What do you think about those two areas or ideas?
Marc: I’m not sure why the reproductive endocrinologist (REI) would mention that stress doesn’t impact things. Every REI that I’ve spoken to has said that it does. There is an interesting research article published by a couple of ABORM fellows and a reproductive endocrinologist showing how cortisol levels are regulated during an IVF cycle using acupuncture. For me, anyone who would say otherwise surprises me. It’s pretty clear. We know that stress impacts any medical condition.
Are there some individuals who are more resilient? Sure. Everyone adapts differently. However, I’ve had patients whose ability to conceive shifts even after five minutes a day of regular meditation.
I hadn’t thought about conception rates going up during wartime. I would imagine there was fluctuation and then self-regulated as people became accustomed to the fact that we were at war. Those numbers would probably adjust on their own. There’s a difference between being in war actively versus us as a country being at war but you are at home. Certainly, there is accommodation but the stress is different.
Georgie: I know a lot of people throw ideas like this around casually. From what I’ve observed, it’s evident that stress does play a role so I appreciate that idea.
Marc: a good example is, “how come that drug addict can get pregnant and I can’t? And they’re taking drugs?” Wouldn't that be a source of stress and toxins in the body? They are. Typically, however, the individuals you see who are addicted to a drug are younger. Their reproductive response is going to be different.
Too, they’re probably under the least amount of stress when they’re high. They’re in euphoria. They’re relaxed. And that’s probably when things are happening.
Because it’s not viewed as a positive thing to be addicted to drugs, we focus on the harm. But there are other things to consider in those situations.
It’s easy to compare yourself to other people who are getting pregnant. We’re all different. We’re all unique. We all have our own issues or situations to overcome. Every other person will be different from your situation. One person’s weakness is digestion, another person’s weakness is something else. That’s where these customized plans and getting to the root issue for people makes the most difference in reproductive function.
Georgie: there are underlying conditions that impact conditions other than just fertility. Women from our Facebook group were asking about Hashimoto’s and PCOS. How can Chinese medicine help women with those conditions?
Marc: the research that has been done in Western countries around Chinese medicine has almost all been done in acupuncture. That is changing. We are seeing more research in broader areas. Most typically, research has been in how to support and make IVF more successful. Part of that is because IVF is so expensive, we want to minimize the amount of cycles someone goes through.
There is so much more Chinese medicine can offer to someone’s fertility journey. Hashimoto’s and PCOS are some of those things. I would add Endometriosis. Any condition you have that could impact your reproductive health, whether or not you’re trying to get pregnant, can be improved by acupuncture. Acupuncture has successfully treated people for thousands of years.
1. PCOS is the most common female endocrine disorder. Acupuncture can help with ovulation. Of all of the non-IVF research in Chinese medicine, PCOS is at the top of that list. We have good research to show how acupuncture can support PCOS and help regulate their cycle. We can cause women to have more ovulation and a more regular cycle, which gives her a higher chance of natural conception. We routinely see this outcome.
2. Thyroid and Hashimoto’s are a little different. With thyroid disease and hypothyroidism, one aspect of their treatment should be medication if they are planning to conceive. For the long-term health of the mom, pregnancy and baby, it is much better to be stable and on medication. For Hashimoto’s, we all need to understand that it is a variation of hypothyroidism, a more extreme case. It is the autoimmune component of hypothyroidism. The medication treats hypothyroidism, not Hashimoto’s. I like to work with patients who have this disease and get them on medication. Then, we can use Chinese herbs and supplements to support the autoimmune issues.
Georgie: are there issues with diagnosis? I know there are differences in what a normal, acceptable thyroid level is. I’ve heard that testing for Hashimoto’s is increasing. Getting diagnosed, much less getting treatment, is an issue. Does it manifest differently for different people?
Marc: absolutely. I don’t use symptoms as my only guide for testing patients for thyroid issues. I see most patients have their TSH checked. When you take medication, that’s what you’re treating. If someone has had “thyroid testing,” that’s pretty much all they’ve had done. I’ve seen countless patients where TSH is normal but their other thyroid values and bodies are abnormal. You need a comprehensive thyroid panel, which I typically run for all my patients regardless of symptoms.
Georgie: women need to be armed with the right information when they go to their clinician. Perhaps you could talk a little bit about what the tests are for a full, thyroid panel. What does a woman ask?
Marc: you should list the tests out. Don’t be surprised if you go to your GP, OB or REI and ask for a thyroid panel and they say no. Or, you’ll get the results back and it wasn’t a full panel. They’ll order a TSH with reflex. If the TSH comes back as abnormal, it triggers the lab to run additional thyroid tests. However, if the TSH is in normal parameters (which is large, 0.4-4.5 or 5.4), they won’t test anything else. I don’t like to see anything over a 3 but I do that and it has been ignored.
Physicians are influenced by the medical system they work within and the insurance plans they work with. They may not see the need. There are many variables at play when they decide whether to order the labs. You can take control to order labs on your own, which I encourage patients to do. Or, if you have another health provider who’s part of your team, they can order that for you without much fuss.
If you’re going to ask, you want:
Georgie: I had this happen recently. My OB/GYN said they would only order TSH. I knew that people disagree about a normal TSH level so I asked for a thyroid antibody. The statement that was shared with me was, “I am not an endocrinologist, I don’t order that.” I feel I shouldn’t have to go to a specialist for blood work so I pushed and my doctor ordered it. I felt like I was being inappropriate but I was really just standing up for myself!
The education you’re providing is important for people to know.
Marc: I hear that sort of story all of the time. It will be more difficult if you’re in a HMO to get the lab tests ordered than it would be a PPO. Even still, it can be challenging. You have to be an advocate for yourself, not just for this but for your entire fertility care and push for the things you truly believe you need to be tested for. It’s not sufficient for someone to just say, “no, you don’t need it.” You can say, “show me I don’t need it. Run the test and then we’ll move forward.”
Georgie: there are different kinds of practitioners. I’d love to get your thoughts around PCOS and some of the traditional ways and some of the Chinese practices you’ve worked with women on.
Marc: when we were talking about PCOS before, I by no means meant to minimize it. Often, we talk about the symptoms of PCOS that include unwanted body hair, elevated hormones, acne, etc. Only a few of my patients with PCOS have those symptoms. 50% are atypical: they’re thin, have a regular cycle with some variation. There are four or as many as 10 different types of PCOS depending on the parameters. You might not have the full-blown syndrome but be polycystic in some form or fashion.
With regards to medication, everyone should understand that metformin is used off-label to help with PCOS. Drugs like this can help some people with PCOS. It’s not a magic pill. Inositols are also used. Many drugs used for PCOS are actually meant to help with blood sugar. These drugs don’t help with everything. You have to address all of the areas, including lifestyle and diet. Acupuncture and Chinese herbs are important because they reduce androgens, help follicles to mature, regulate menstrual cycles and support ovulation.
Georgie: let’s talk about some of the tactics around acupuncture. In my 10 year fertility journey, I saw REIs and acupuncturists. I had one extreme of acupuncturists, where I showed up and had no questions asked. As I started learning, I would try different practitioners. At the other extreme, they sat with me and asked all sorts of questions about my life and body. They would use needles at custom trigger points based on those answers.
What should an acupuncture appointment look like? Is there a plan of treatment, or do you go for the rest of your life? What should we expect?
Marc: I’ve had this experience. When I started acupuncture, it helped me so much. Two years went by and I was going every week. I thought, “I’m better. I wouldn’t go to my medical doctor each week.” I’m very clear with my patients about a plan and prognosis. To some degree, acupuncture is an art which means there is individuality and variation between providers.
We do a full visit and exam with our patients. We’ve had some patients ask, “why are we doing this? Can’t you just give me an exam?”
We are medical professionals. I am a doctor of Chinese medicine and acupuncture. Your doctor does an exam before they know how to treat you and what recommendations to offer. They’re not going to say that you need medication or surgery without evaluating you. We can’t properly diagnose you without an evaluation. Part of this is paperwork, questions, pulse diagnosis, tongue diagnosis, visual analysis, lab review and more. In my office, it’s a combination of all of those things to create the proper diagnosis for patients.
First and foremost, we should all expect that from our medical professionals and Chinese medicine physicians.
In my office, after my evaluation and after I have enough testing, I do write out a treatment plan for patients. It’s important for them to understand where we are and where we want to go and how we’re going to get there. I can’t assume that I’m going to get results. At the end of my treatment plan, which usually starts at 3 months, we sit down for a reevaluation. We assess progress. I always want to be accountable to myself. We can’t always remember where a patient was when they started so we review that and see what has changed and what hasn’t. Then we decide, “where do we go from here?” That’s a partnership. That’s a conversation we have together. Maybe their timeline has changed. I want to meet them where they’re at and support them through that process without making assumptions.
When patients are doing well, they forget how bad things were. It’s helpful for everyone to perform that review and revisit goals.
To go on endlessly seems odd to me. There are patients who love it and find great value in it but that’s a personal decision.
Georgie: when I found a great acupuncturist, I stayed with her and now go every single week.
We’ve talked before about how on the west coast and east coast there are different rules for acupuncturists. State regulations impact what clinicians can do. Can you elaborate a little bit on how laws impact treatment?
Marc: this is an important piece that is often overlooked. Just within the fertility world, you will see that treatments differ. In New York, they can’t order labs. In Florida, they can do it all including trigger point injections and ordering medications. In California, we are primary care so I can order all sorts of labs and do things that colleagues in other parts of the country are restricted by. This is a state by state situation. I don’t know the laws in each state but what you should be asking your acupuncturist is, “what are you able to do for me? And do we need to work as a team with someone else to get me the most comprehensive care that we need?”
In my office, I work in conjunction with other medical providers in case I do encounter something that I can’t provide. You need to work with someone who is comfortable and understands the parameters. Medicine is practiced differently in all parts of the world. We should try to understand that when it comes to your reproductive needs and your fertility needs.
There’s a lot of talk right now about PRP or other treatments that aren’t available to people locally. We often work with a lot of patients who do mini-IVF, which is a low-stimulation or no medication IVF process. That isn’t practiced in most clinics. There are many reasons you need to understand what your local providers can offer and what you need/where you might need to go for other options.
Georgie: what is your greatest hope for women’s reproductive health?
Marc: it’s twofold. The couples who have been told “no” or “you can’t” don’t take that as a final answer. I want them to believe in themselves again and get the answers that they need. In most cases, there is hope and there is possibility. But we’ve been knocked down so often that we start to believe the negative talk.
I hope that we start to see a lot more collaboration between allopathic treatments and the integrated, Chinese medicine world, to provide pati