EAST MEETS WEST: Toward an integrated patient-centered model of fertility care

Until recently, Chinese medicine and Western medicine have existed in two separate solitudes -- with little knowledge or understanding between them. This fragmentation has been frustrating for both physicians and patients alike and, in the case of fertility care, may have an impact on the health of the patient. When I first opened my fertility acupuncture clinic in 2000, there was almost no communication between acupuncturists and IVF clinics: most of my patients were reluctant to tell their fertility specialist they were getting acupuncture, and many REs were highly sceptical about the benefit of acupuncture for fertility.

Increasingly, however, the schism between Eastern and Western medicine appears to be closing. Many leading IVF clinics in the US and Great Britain offer acupuncture services, including on-site acupuncture support for IVF transfer. While Canada is still catching up, in my practice I have seen a remarkable change in the relationship between our clinic and local IVF clinics. I now regularly communicate with REs about patient care. We have co-presented public information talks on integrated care, and, as of fall 2008, we will be providing on-site acupuncture treatment at the time of transfer for one of the larger IVF clinics.

What is driving the change?

The two main factors driving a more collaborative approach between East and West are patient demand and the growing number of scientific studies suggesting that acupuncture can improve the outcomes of IVF.

Consumer demand for complementary and alternative medicine (CAM) in general is growing exponentially. According to a 2006 Fraser Institute survey, Canadians spent approximately $7.8 billion out-of-pocket on alternative medicine in the year before the 2006 survey. Of the more than 50% of Canadians who used CAM during this time, over half of them state that they did not discuss the use of CAM with their doctor.

In fertility care, the number of patients using CAM may be even higher. Although there are no statistics for Canada, a study in Australia shows that some 66% of patients seeking treatment at fertility clinics use complementary medicines and therapies alongside prescribed medication -- and the fact that many do not share this information with their fertility specialists could have an impact on their treatment.

Studies show that patient satisfaction with fertility treatment increases when patients:

• Feel respected and treated as partners in their healthcare
• Have a sense of control and choice over treatment
• Feel that their distress is recognized
• Feel cared for and have trust in their health care professionals

Acupuncture is one of the most widely used and most studied alternative fertility therapies. The March 2008 edition of the British Medical Journal published an article examining seven studies in which 1,366 women undergoing IVF had either acupuncture or a sham form, or no treatment at all. The study found a measurable increase in pregnancy rates among the acupuncture group. Studies like this are increasing the confidence of MDs about the benefit of acupuncture. (Manheimer E, Zhang G, Udoff L, et al., "Effects of acupuncture on rates of pregnancy and live birth among women undergoing in vitro fertilisation: systematic review and meta-analysis." BMJ 2008; 336 (7643):545-549.)

As fertility patients increasingly seek therapies like acupuncture as an adjunct to conventional fertility treatment, and as research demonstrates that acupuncture can improve IVF outcomes, we need to develop models for how to best deliver integrated care.

What is integrated care?

Integrated care goes beyond the usual definition of CAM, where alternative and western medicine treat the same patient with little or no understanding or communication between the different medical modalities.

A paper published by the Prince's Foundation for Integrated Health in the UK describes a vision of integrated care that embraces five essential components. (Dr. Michael Dixon OBE, "Returning the Soul To Medicine: a vision of integrated general Practice in the 21st Century." The Prince's Foundation for Integrated Health, 2008.)

1. Integrated care is a patient-centred approach that treats the whole person. It recognizes the importance of the patient's perspective, culture and belief system and understands that each couple/individual is unique and comes with their own personal story. Treatment is the result of a dialogue between patient and healthcare practitioners in which they decide, together, the most appropriate course of action.
2. Integrated care involves an open-minded approach to treatment, focused on helping the patient choose the safest, most effective and most appropriate conventional and/or complementary treatments to address their particular needs.
3. Integrated care extends beyond the symptom or disease to include a focus on the patient's overall wellness, wellbeing and quality of life.
4. Integrated care involves the patient becoming an active participant in their own healing process. The role of the integrated healthcare practitioners is to help patients learn to take appropriate action for their health through coaching, advice and education.
5. Integrated care includes a shared-care approach in which a range of health professionals share responsibility for an individual's care. This approach includes sharing skills and knowledge between disciplines as well as monitoring and exchanging patient information.

Integrated care provides patients with choices and a wider range of therapeutic options for their fertility care. This is especially important for patients who wish to pursue more natural options or who have lifestyle issues that are impacting their fertility.

Chinese medicine, of which acupuncture is one form of treatment, is particularly suited to an integrated approach. While most of the research and medical attention has been focused on acupuncture for IVF on the day of transfer, the real benefit of integrating Chinese medicine with Western ART may be the preconception care that Chinese medicine can provide in the 4 to 12 months prior to conception.

Chinese medicine has a long history of treating gynaecological disorders and infertility with diet, lifestyle changes, stress management and, if necessary, herbal treatment and acupuncture. Chinese medicine stresses food therapy. With its emphasis on moderate eating, whole foods and a plant based diet with a rainbow of fruits and vegetable, the Chinese Medicine diet resembles the low-glycemic antioxidant-rich fertility diet recommended in the November 2007 edition of Obstetrics & Gynecology (J. E. Chavarro, J. W. Rich-Edwards, B. A. Rosner, and W. C. Willett, "Diet and Lifestyle in the Prevention of Ovulatory Disorder Infertility." Obstetrics & Gynecology, November 1, 2007; 110(5): 1050 - 1058.)

Most busy IVF clinics do not have the resources to provide stress management, lifestyle coaching and nutritional support to patients. By providing this support, Chinese medicine practitioners can offer a valuable adjunct to western fertility treatment. Patients report that combining ART and Chinese medicine empowers them to take charge of their own health. Overall health benefits like weight loss (when needed), deeper, more restful sleep, less side effects from fertility drugs, more energy, and a greater sense of ease with the whole process of their treatment gives patients an enhanced sense of control and well-being which, in turn, improves the sense of satisfaction about the whole fertility journey -- regardless of outcome.

In addition, patients report feeling increased trust and confidence when their healthcare providers are working together as a team. At the same time, enhanced communication between IVF clinics and acupuncturists ensures that REs are aware of what alternative treatment patients are taking and that everyone is on the same page regarding treatment protocols. For example, many REs are not comfortable with patients taking Chinese herbal formulas leading up to and/or during an IVF cycle. With good communication, concerns like this can be addressed and appropriated protocols developed. Currently in our practice, patients who are on an IVF cycle stop taking herbs. This is just one example of where working together and good communication can ensure that treatment is harmonized.

Benefits of integrated shared-care include:

• Increased continuity of care
• Enhanced trust
• Improved working relationships between providers
• Increased patient satisfaction
• Improved success rate

Secrets to successful, integrated care

As research demonstrates the benefit of integrated care both in terms of improved outcomes and enhanced patient satisfaction, and as the demand for integrated care increases, the question remains as to what is the best delivery of integrated care. Integrated care is still in its early stages in Canada, and how it is practiced depends on the individual IVF clinics and CAM practitioners involved. In some cases, IVF clinics may provide integrated care in-house with a resident acupuncturist; however, a more common model is a "virtually integrated clinic" comprising affiliated practitioners who have their own clinics. In this case, the acupuncturist might be on site at the IVF clinic to provide acupuncture at the time of transfer.

Factors for success include:

• Education: A willingness on both sides to learn about the other's medical modality. Rounds, staff education, and lunch and learn sessions are all ways for acupuncture and IVF clinics to become familiar with each others' terminology and treatment.
• Leadership: Commitment at the medical director level is critical, as integrated care takes vision, dedication, time and resources.
• Resources: Clinics must be willing to dedicate time and staff to developing and implementing integrated care.
• Case management: Integrated care requires physicians who believe in the value of integrated care and are willing to educate patients about valid complementary and alternative treatment options and to take the time to communicate with the Chinese medicine practitioner.
• Communication: Regular communication between the Chinese medicine practitioner and the case physician(s), including e-mail, phone and face-to-face discussions help ensure that all parties are aware of issues and treatments, and that the delivery of care is consistent. IVF clinics and Chinese practitioners need to receive informed consent and confidentiality release documents from their patients to be comfortable sharing files and information about them.
• Flexibility: Integrated care is a work-in-progress and requires flexibility in designing and re-designing treatment protocols to best suit the patient's condition and needs.
• Internal alignment: It is important that clinic staff are educated and on board with the idea of integrated medicine, and appreciate the contribution acupuncture and Chinese medicine can make to patient care.
• Protocols: Differences of opinion or philosophy between Chinese medicine practitioners and MDs are inevitable. Mutually established protocols with clear boundaries and areas of responsibility can resolve many of these differences.
• Legal Guidelines: It important for IVF and Chinese medicine clinics to know and operate within their legal and professional guidelines.

What to look for in Chinese medicine practitioners

Along with being licensed/registered in their province, Chinese medicine practitioners practicing integrated fertility care need to have experience and training in both Chinese Medicine gynecology (a specialty of Chinese medicine) and Western ob/gyn procedures and fertility treatment. Currently, the College of Traditional Chinese Medicine of British Columbia (CTCMABC), the licensing body for Chinese medicine in BC, does not have a specialist certification or recognize specialization.

However, the American Board of Oriental Reproductive Medicine (www.ABORM.org), in response to the burgeoning field of fertility acupuncture in North America, has created a certification demonstrating that Chinese medicine practitioners have knowledge and training in TCM gynecology and a working knowledge of ART treatment, testing and terminology. The ABORM holds an annual certification exam and provides a list of acupuncturists in North America who have successfully completed the exam and have the certification of FABORM.

The future of integrated care

The practice of integrated care requires a shift in the way we think of medical care and the role of healthcare practitioners, from a purely biomedical model based on treatment of presenting symptoms and diseases to a patient-centred model that treats the patient as a whole person and recognizes the patient as an active participant in their own health care. It acknowledges that health conditions are multifaceted and include environment, lifestyle and patient attitude. Integrated care requires a team approach to patient care and the recognition that other health care modalities like Chinese medicine have an important role to play.

Integrated practice takes time, commitment and resources. It is challenging for busy practitioners and IVF clinics to dedicate the human and financial investment necessary for developing and implementing an integrated practice. However, the increase in patient satisfaction, patient referrals and health outcomes can make this investment worthwhile and highly gratifying for all parties involved.

Fertility treatment is leading the way with integrated care. However, this shift has positive implications beyond fertility treatment. As a new model of health care, integrated care can make a major impact on public health by educating and empowering individuals to be active partners in their own health and wellbeing, and, ultimately, contributing to a more sustainable healthcare model and to healthier communities.