SART Fertility Experts: Complimentary and Integrative Medicine in Reproductive  Care and Infertility Treatment

Is there anything beyond pills, shots, IUI and IVF?  In this episode, we will discuss the role of Complimentary and Integrative Medicine (CIM) and its role in infertility treatment.  Listeners can learn about the role of acupuncture, supplements and other treatments that may be offered to optimize reproductive medicine therapies.

Hello, my name is Brooke Rossi and I am a reproductive endocrinologist and infertility specialist practicing in Columbus, Ohio. And we are recording for the SART Fertility Experts podcast series. Today, I have the pleasure of meeting with Dr. Niki Rarig.

She is a licensed naturopathic doctor and acupuncturist practicing in California. She specializes in reproductive medicine throughout the hormonal lifespan, treating patients undergoing infertility treatments with insemination and IVF, and even perimenopausal and postmenopausal patients. Dr. Rarig is also the chair of the ASRM Complementary and Integrative Medicine Special Interest Group.

Dr. Rarig, I'm so happy to have you here today to talk with us about complementary and integrative medicine treatment and infertility treatment. Thank you so much for having me. I'm so excited to be here.

So I think first, let's just learn, how do you define complementary and integrative medicine? All right. So complementary and integrative medicine is a very broad category of providers and researchers. Our CIMSIG, so the Complementary and Integrative Medicine Special Interest Group at ASRM, we are acupuncturists, naturopathic doctors, REIs that have a special interest in integrative medicine, researchers, embryologists.

It's a big group of nutrition, dieticians, mental health providers. I mean, the list could go on. It's really just people that have an interest in providing integrative medicine and incorporating that evidence-based into a conventional medicine treatment plan.

Right. So it's complementary and integrative medicine is, by definition, it's integrated and part of maybe a more, you might say, traditional treatment plan. I think that a lot of our patients may be familiar with mental health practitioners, nutritionists, but can you talk a little bit about, like, you are a naturopathic doctor.

If you can just mention a little bit about your training and how acupuncturists, because I think a lot of patients understand acupuncture, like, what is that training like specifically for people who are interested in reproductive medicine? So what is the education? Yeah. Yeah. So my background, I went to National University of Natural Medicine in Portland, Oregon, and I did a master's in traditional Chinese medicine.

So that's a four-year master's degree and then a four-year doctorate in naturopathic medicine. And at that school, you can do it concurrently with some overlap in six years. So that's my background and training.

In certain states, so states like Oregon, naturopathic doctors are considered primary care physicians. So we're trained. Oh, interesting.

Okay. To practice kind of full scope primary care. So prescribing medications, doing full lab workup, you know, managing someone's health care.

Would you recommend, it sounds like, much like other types of maybe more traditional medication or traditional treatment, somebody like you or has a special interest in special training in reproductive medicine and maybe even women's health, would that be something that you think is important as patients are exploring different treatment options maybe in their community with different acupuncturists or practitioners? To find someone that has a specialty. Yeah. So when someone's looking for an acupuncturist and they're going through potentially fertility treatments, you know, IVF, it is definitely important to find someone that has a specialty in reproductive medicine because you don't want the patient to have to be kind of teaching the acupuncturist what IVF is, you know.

Right. Someone that already, you know, has that down, like knows what they're doing, knows how to safely and most effectively incorporate acupuncture into a treatment plan. So there is a good resource, ABORM, which is the Acupuncture Board of TCM and Reproductive Medicine.

And that is, I'm an ABORM fellow. So it means that this is an acupuncturist that has had training, extra training in reproductive medicine and has taken an exam. So has passed a test like that was a, I would say it was a pretty hard test.

So I think the bar, you know, it's a good bar. Yeah. If you're finding someone that is ABORM certified, but, you know, they know what they're doing.

You definitely will not have to be teaching them. That's great. Between an egg retrieval and a transfer.

Like, yeah. So tell me a little bit about the patients that you see. Are there certain groups of patients that may benefit more from CIM? Or when you're thinking about who you can really help, like who's in that group? So, gosh, I mean, it's hard not to say just like everybody.

Everyone. Right. There's of course something everyone can benefit, I think, from seeing someone that's going to be looking at them with a really holistic whole person approach, looking at their diet, you know, looking at like, how are they handling stress? How are they sleeping? And do you treat men and women? Yes, definitely.

Yeah. Tell me a little bit about maybe how you would, I mean, obviously it's different depending on what their issue is, but what are the different things you look at or strategies that you use maybe for anybody or different types of patients? Sure. So I would say I see, I would say women or people who are, you know, going through the egg retrieval processes themselves and that transfers themselves.

Those tend to be the majority of people that come into my practice. And I find it a little harder to get the male partners in. I know that's a common experience kind of across the board.

There certainly are things that we can do for them as well. So when I'm seeing patients that are either just at the start of their fertility journey, or maybe like about to go through IVF or IUI, we're looking at people, you know, we're looking at that person, you know, do they have potentially, you know, endometriosis or PCOS or diminished ovarian reserve? You know, the treatment plans are going to be very different depending on what that person is coming in with. Yeah.

Or maybe it is, you know, unexplained infertility. And maybe we're also going to be trying to, you know, not necessarily, we may not be able to find like the quote unquote root cause of like why that person has unexplained infertility, but we can look at them as like, let's look at all your nutrition levels. Let's look at your diet.

Let's look at your blood sugar regulation. Let's make sure that you're in the most optimal place to go through an IVF. Yeah, that's a good question.

So what are some of the tests or evaluations that you would do on your patients? So as a naturopathic doctor, I do labs and imaging for patients. You know, sometimes I'm seeing people at the very start of their journey, or maybe they've been trying for a year. They don't, a lot of people in my area don't even have a primary care doctor because it's like medical desert for primary care in my region.

I know that's not a common experience across the country. So they may not have had any labs done. So I'm doing, you know, a lot of just like, let's do your basic annual labs.

Let's look at blood sugar. Let's look for anemia, look at thyroid function. Yeah.

And then also I like to do things that are more, maybe not as commonly tested, like an iron panel. I mean, it's like nothing fancy, but iron ferritin is so under tested in the population. And so many people are iron deficient.

And that does have an impact on fertility and miscarriage risk. So I find that that's so important to get people into optimal levels before they're entering a pregnancy. Like if you were to put your like acupuncturist hat on, what kind of testing or evaluation would you do in that scenario? Is it any different? So an acupuncturist is going to be approaching a patient.

It's a little bit of like a different hat that we're putting on when we're evaluating a patient. So we're assessing more from a traditional Chinese medicine lens, like you feel the pulse and not just like the rate of how fast the pulse is going, but kind of like the subtle qualities that the pulse feels under the fingers. So people might feel like they have like a quote unquote wiry pulse, which is very like tense.

And that's kind of one constitutional assessment versus someone that has like a really like thin, weak pulse is another, it's like more of a deficient patient. And those patients are going to be treated very differently from a Chinese medicine perspective. It'll be different acupuncture points, potentially.

If you're using Chinese herbs, it's different herbal formulas that those types of patients are going to respond to. Okay. Yeah.

A little bit different way of assessing. Yeah. And so it sounds like what you're saying is a lot of the maybe evaluation you would do as a naturopathic doctor might be a lot of the same evaluation that we're doing.

And in fact, some of the initial treatment suggestions, which would be things like diet, exercise, stress management, all that kind of thing is probably very similar to what we as, you know, myself as an MD would be doing as well. So that's all interesting. And then, so I only know the patients that I see that then I sometimes will send to providers like you.

Do you sometimes find that you will be sending patients to, you know, like REIs as well? Yes, absolutely. Absolutely. I mean, I think the worst thing that we can do is keep patients for too long, you know, if they've been trying for multiple years and they may be advanced age, you know, I think doing a referral to a reproductive specialist, you know, sooner than later is often a good thing just so they can know what their options are.

Yeah. They may not choose to pursue IVF, but I at least want them to know that it's an option and to find someone that, you know, they feel comfortable working with if they choose to go No, I agree with you. I think patients really want to have all of their options.

And in addition to that, you know, having infertility is very, they feel a lack of control. And so I think a lot of patients, you know, want to do, want to feel like they're doing as much as they can and they are seeking other forms of treatment beyond just maybe what we're doing in like our REI office. They want to say, I want to do this other thing.

And so I do think they appreciate a lot when I say, hey, have you thought about seeing an acupuncturist? They are really excited to have that as an option. Yeah. So that's, I think it's a great option for people.

And I think we used to be called the Complementary and Alternative Medicine Special Interest Group. At a certain point, we moved away from that and became the Complementary and Integrative Medicine Special Interest Group. And I think for that reason, like we're not trying to say this isn't either or.

It's not an, exactly. It's not an alternative, like either what I do or you do is not an alternative. It's just in addition to.

And I think that the patients definitely benefit when we're together. And I, you know, hate for patients to feel like they're stuck in the middle and they, you know, there is data showing that like so many people that are going through IVF treatments are utilizing acupuncture and utilizing even herbs and are not always telling their REI about it because they don't really feel comfortable and they think they're going to be judged and they think they're grateful not to do that. Or they'll be told, yeah, don't do that anymore.

Exactly. And part of that is that we just don't know. Right.

Right. Sometimes I will, you know, I don't know enough about, for example, herbs or other things they may be getting to know if that's going to somehow interact with what I'm using. And so it would be a good collaborative approach to be able to talk to the provider and that sort of things as well.

And yeah, just to clarify, I don't generally use herbs when someone's actively in an IVF site. Yeah. Like that, you know, maybe when they're in between cycles.

Yeah. You know, when they're not, you know, taking stins or. Yeah.

I think that's very common. And that's what most people I would say that are like in the aborm. Yep.

Would agree with that. Yeah. Generally we stay away from that.

Okay. I want to ask about a few specific conditions just to kind of pick your brain about what you think and provide. So first I'm thinking about, we talked a little bit about endometriosis, like what kind of services or how do you approach a patient with endometrial or who we think has endometriosis as their primary etiology for infertility? Sure.

So I see a lot of people who either have been diagnosed with endometriosis or it's just highly suspected. I use a lot of acupuncture to support my endometriosis patients. I mean, we have some good data.

There was a study published a couple of years ago in fertility and sterility about using acupuncture for pain management and endometriosis. So it definitely has a lot of reason to use it for chronic pain management. We are very helpful.

And acupuncture is so helpful for many types of chronic pain management, you know, back pain, headaches, all sorts of things, and also improving quality of life in those patients. We don't have any specific studies on using acupuncture for patients specifically with endometriosis going through IVF in terms of birth outcomes. And I just need more research.

I would love for that study to be done because I would love to. Do you ever talk to them about any other lifestyle or diet modification when they have endometriosis? Yeah. Yeah.

So really moving and for, I mean, most of my patients moving towards more like Mediterranean style eating, you know, limiting refined sugar and processed foods and moving towards just like whole food diet, you know, more fiber, more fruits and vegetables, helping with, you know, regular protein intake for good blood sugar balance. I mean, that's going to be more of like an anti-inflammatory diet approach that can have good support for endometriosis patients, for PCOS patients. Yeah.

I've had patients with endometriosis feel tremendously better when they are very, being very careful about their diet. And, you know, and I don't know, we know if we don't, you know, we don't know exactly how it's helping their fertility, but I imagine feeling better is a good thing. Yeah.

And quite a few patients with endometriosis will feel better on a gluten-free diet. Yeah. Whether or not they have celiac disease or not.

Yeah. I just am really cautious to... Give them that diagnosis. Yeah.

Of course. To put people on restrictions because some people are already coming in and they're they've already cut out dairy and gluten and sugar and they feel and all of a sudden they're eating just this like really narrow diet that they feel like they have to do if they're going to get pregnant. And so a lot of the times I'm actually trying to get them to eat more and incorporating more.

Yeah. And maybe part of it is just telling them, I think people are so worried that what they're doing something wrong and really you almost need to say, this is not, like it's out of your hands. Like, let us help you.

There's nothing you can do about this and try to get them to, you know, not feel like it's all up to them because often it isn't. And a lot of endometriosis patients will feel better on a low FODMAP diet as well, which is limiting certain like fibers and starches. Oh, okay.

It's not my favorite diet because it's really not like the healthiest diet. You're like broccoli and beans, you know, all these like gas producing foods. Yeah.

There is data to show that endometriosis patients will often feel better on that diet. I just think of it as a temporary solution and not necessarily a long-term thing. Okay.

And those patients that find they feel better on that type of diet, I'm always wanting them to get evaluation for their digestion because they often feel better because they're less bloated and they have digestive symptoms. And so there's probably an element of like dysbiosis and, you know, microbiome imbalance in their gut in those patients. I like to work them up for a small intestine bacterial overgrowth and then do treatment for that.

So then they can eat those healthy foods again and start treating their gut bacteria. I understand. I understand.

Another population I wanted to ask you about is patients maybe who either have infertility or don't, but have recurrent pregnancy loss. Do you see those patients? Absolutely. And that's a very tricky group to work with because oftentimes we don't know why they have recurrent pregnancy loss.

It's such a roller coaster for them emotionally. And we often, yeah, can't ever put our finger on the like one, you know, cause. And so there's not a lot, we don't have specific data on that population in terms of like using acupuncture to, you know, improve their pregnancy outcomes necessarily.

We have some mixed data about some of the studies show a lower miscarriage risk and some don't. So it's a tricky, it's a hard population for REIs as well to take care of. But I think we do know that in terms of we're talking about acupuncture, that acupuncture can really help with infertility related anxiety.

And that population is, you know, people experiencing recurrent miscarriage, like definitely have, you know, a lot of anxiety, depression. It's a big emotional roller coaster. Right.

So I think that we can be supporting those patients just to like get through the process with, you know, and feel better. Yeah. And just be another support person on their team.

The other population, which is I think probably similar to that population is our recurrent implantation failure population. And that may, I mean, it's a newer population for us and maybe even for you as well, but I would love to see if there's anything, you know, like people who are doing CIM can help with that population as well. Yeah.

So for recurrent implantation failure, I know of one study that looked specifically at acupuncture in this population and did show some improvement or you know, potential association with successful birth outcomes with using acupuncture. I can only, I only know one study that shows. Right.

So of course we need more data. Right. And I would say, so specifically for that population, I'm going to be looking at, again, we don't totally know what's causing that recurrent implantation failure, but acupuncture in terms of its mechanism is going to improve blood flow to the pelvic organs, have the potential to thicken the endometrial lining, you know, leading up to transfer or implantation.

So there is potential just from a mechanistic perspective to, you know. Yeah. So that's actually, that's a great question.

So how does all of this work? And maybe that's a really too big of a question to ask you. So maybe if we focused on acupuncture. Oh yeah, yeah.

So tell me a little bit about, so I think, you know, a patient that I have sent for consultation with acupuncturist is patients who have thin endometrial linings when they're doing IVF. So can you talk a little bit about how acupuncture may work or any other types of treatments that you do that may, how it may work? Yeah. So if we're focusing on acupuncture, we have a few theories as to, or, you know, what we can, what we know from the data as to like what the mechanisms of how it's working.

It's working with the central nervous system. So it helps to relax the patient. It helps to encourage blood flow to the pelvic organs.

So that's going to be, you know, your uterus to also improve, you know, blood flow to the uterine lining. It's going to improve blood flow to the ovaries and blood flows to the testes. So we do have data showing that, you know, that's also happening in men.

And then it also, and we have some data in PCOS patients that is showing that it helps with insulin regulation and blood sugar regulation. So helping with the skeletal muscles uptake of glucose. Interesting.

Okay. And again, these are small studies, but it is like indicating that this is, you know, things that we could potentially be helping to improve like neurotransmitter regulation and increase endorphins, increase opioids, natural production of opioids. So for helpful for pain relief, for just feeling good, first anxiety, stress, all those things.

Okay. And also for helping with the HPO access to help with basically like hormone regulation in the body. So in PCOS patients, we actually have seen that it can lower testosterone levels and improve LHFSH rate.

Okay. Which hopefully will help them ovulate more easily and great. And again, small studies, but we're seeing indication that acupuncture can improve more regular.

If we're improving the blood flow to the ovaries, does it help women with decreased ovarian reserve? Yes. And that's a lot of the people that I tend to see. We see that, you know, people that are tending to find us are often have had failed cycles, you know, are potentially older, are needing to go through more treatment.

So they're trying to figure out what, you know, what else is out there? What else can they do to like have the next cycle be more effective? And so we're trying to still figure out in terms of, again, with acupuncture, like what's our ideal age group, you know, what are we most effected in? There's some studies showing maybe like a 38 to 40-year-old population or 42-year-old population is like they might get the most benefit. People that have had failed cycles previously, and they may be starting at like a lower baseline rate of pregnancy than someone else. So we might be having more effect in that group than maybe someone that's, you know, younger and, you know, their rate of pregnancy is probably going to be higher no matter what.

So I'm hearing what you're saying, and I'm thinking to myself, if I have a patient who's 40 years old, who's failed a cycle and wants to pursue some sort of CIM, you know, time is of the essence a little bit. And so, you know, the acupuncturists that I've worked with, you know, they have a lot of work to do and they need time just like we need time to do what they need to do. So like in a perfect world, how much time do you need to like, quote, get a patient ready? And then how do you also manage things like age or another example would be maybe a patient who's struggling with her weight and has gotten her weight down from medications and now is worried about her weight going back up.

Like tell me a little bit about, that's a lot of questions I ask you, but... When should people start to see us, like during their... A little bit, like and how do you balance age and doing what you need to do with what, you know, maybe we need to do with IVF treatment and trying to get the patient back to try another IVF cycle? I mean, I think in a perfect world, if we're able to see someone and they know they're going to do IVF, like if we can start seeing them three months before that cycle is going to start, that's like ideal. Just a little like physiology side point for me is that, you know, we do know that the eggs and the sperm take about three months to be made. So you're, you know, like your desire to see them for three months is, makes physiologic sense.

Right. So that's, I think, in a perfect world. Sometimes though, you know, I'm definitely never telling people if they're like 40 years old and they start to see me and they're about to do IVF, I'm not like, oh, wait.

Yeah, of course. Never tell someone. Do the best you can.

Right. Like we'll just, yeah, it's never too late. Right.

I mean, some people I'll have call me and they're like, I have a transfer tomorrow. Can I see you for acupuncture? And I've never met this person before. And so that's not the ideal situation.

Right. But I still think even just getting one or two treatments in on transfer day, like there's some data suggests that that, I mean, that has benefit. There's actually quite a few studies just looking on day of transfer.

Yeah. Yeah. I have had patients who have like, you know, gone to the acupuncturist, come for their transfer and then go back to the acupuncturist afterwards.

And it's wonderful when there's clinics that actually have onsite access. Oh yeah. I mean, that's like, again, perfect world.

Right. But so, so ideally you may see a patient if possible for a few months before. And this, I would imagine, would be for the men or for the women.

Absolutely. And again, I mean, if we get a semen analysis and got some, you know, not ideal sperm parameters, then they're going to, you know, change some lifestyle habits and maybe get some acupuncture. Yeah.

Ideally you want to have them be coming in for three or four months to really see any change on their next semen analysis. So it sounds like there could definitely be some benefit to these treatments. Do you feel like there's any significant risk to CIM or anything we need to let patients know about that they need? Or are there any patients that aren't good candidates for CIM based on their medical histories or anything? I would say for acupuncture, I mean, the biggest side effect is just going to be a little, potentially like a few drops of blood or a little bit at the needle site, maybe a little discomfort at the needle site, but nothing really significant.

Like if patients are taking anticoagulation medications like Lovinox, can they still do acupuncture? Can still. I mean, I just warned them they might have some thing. It's not going to be anything.

The needles are very small. Yeah. They're getting injections other times.

It's true. Yes, of course. Like not the same needle.

So yeah, there's not, I would say a not a good candidate for acupuncture specifically would be someone that has like a true needle phobia. Right. It's really like, I don't want them to have a big cortisol rush on their table and be, you know, sweating and feeling for, you know, and there are certain people that they just.

And there's probably other things you can offer them besides acupuncture. If they, if you, if they wanted some sort of CIM, you could just do something else. Yes.

And there's even some research on using a TENS unit, a home unit and using it on the acupuncture point. Okay. Not using it in the same way we use TENS for like, you know, the muscle contraction, pain management, but using it more as acupuncture stimulation.

And that actually can improve fertility outcomes according to some studies. Interesting. Or has associated with, you know, improved fertility outcomes in some studies.

So. So it sounds like in general, these are very low risk treatments. Yes.

As long as the patient continues, you know, to like understand that if they are, you know, like in their late thirties that they need to, you know, consider other treatments they may need to do. I mean, it sounds like a great option. What have you found? Now, of course, even in fertility treatments, IUI, IVF varies from state to state with insurance coverage.

You practice in California, what I would imagine is a very liberal state in terms of insurance, but do you find that many of your patients have insurance coverage for this type of thing or? It's very regional and very different. When I was in Oregon practicing where I was trained, oh my gosh, everyone almost had naturopathic medical benefits and acupuncture benefits. I've seen it a lot for pain.

Like, like if they're going, you know, even if it's going to be limited, sometimes it will still be covered for pain. So an endometriosis patient may be able to see an acupuncturist for pain management. Usually, yeah.

Insurance is covering more pain code and fertility code. Right. So yeah, that's definitely something to keep in mind.

Where I am, I'm in a more, I'm considered a rural area in California. So just our reimbursements are so low that so many of us cannot afford to be in network with acupuncture. I mean, it's just for, you know, for acupuncture because they're only reimbursing like under $20 a session.

That's very different. If you're in the Bay Area or LA, I mean, people have such different reimbursement rates. A lot of acupuncturists will be in network.

You know, might have a lot of option to use your insurance, but I'm out of network and I give people super bills and they can get reimbursed that way. Right. And I think it's always, you know, I never, and obviously the same is true of infertility treatment.

Like some patients have coverage, some people don't. And some patients, you know, even if they had to pay out of pocket, it's often not as bad as they may think it is. And so I always encourage patients to at least have a consultation or call the practice and talk to them about, you know, you know, what would it cost for a consultation? What's an average amount they may spend on treatment for an IVF cycle? You know, do they have a sliding scale? Like anything like that before you just, you know, before a patient just says, Oh, I can't afford it.

Like look into it a little bit. And, you know, it's one of these things where you, if it's a small amount of costs to optimize this other IVF cycle that you're paying a large amount for, maybe it would help, you know? Patients, they're like, Oh my God, this is nothing compared to what I'm paying. Right.

And so it's, you know, and at least get the information and don't just think, Oh, I could never do it. And I think it's, what are the average, like in a perfect world, if you saw a patient and you were preparing them for an IVF cycle, how often may you see them? Like during the IVF cycle? So for acupuncture, I mean, I love to be able to start at least three in advance. I may not see them as frequently in the beginning.

I mean, we, it depends on the situation. If they're having a lot of symptoms and they have endometriosis and they're in pain, you know, we might be doing more frequent treatments to address, you know, all those symptoms as well. But if they're, you know, not very symptomatic and we're really just prepping them for that IVF cycle and they're generally like good diet and, you know, they have, you know, everything is pretty much in line.

We're just adding acupuncture. I may see people, and it very much depends on the person. I never want it to be an added stressor, either scheduling or finances.

So we'll work with people and just make it work for them. But maybe seeing people like weekly or even like a couple of times a month at first, you know, whatever is doable for them. As we get closer into the cycle, we'll start to do more frequent treatments once, or even sometimes twice a week as we're really gearing up for an egg retrieval or for a transfer.

And whenever I have a patient doing acupuncture, I'm always telling them, okay, go tell your acupuncturist, here's what your results were today. Because I think, you know, you guys use them to help think, you know, much like I'm changing their medicine on a day-to-day basis, you may be changing your treatment on a day-to-day basis to try to, I love the idea of everyone working together for this like one patient. So.

But I think we don't have enough data to be able to say this is the exact schedule that someone needs to be on. Well, of course. That's how it is when we're doing IVF cycles, you know, as well.

We don't know how many times somebody is going to come in. We have an average, but we never know. So I think we have to just take that and say, well, let's make it work for this patient.

Right. So what's going to be doable for you financially, scheduling wise? I definitely, I know sometimes people are able to, you know, get their transfer and get acupuncture just like on site, which is wonderful right after transfer or their acupuncturist is just right down the street and they can go, you know, easily just pop into the office and get acupuncture. But if someone lives three hours away from an acupuncturist, I'm not saying like, get your transfer and then go make a day trip to go get acupuncture.

That's probably not doable for them, worth the stress. Like, that's fine. Are there any other resources, like good sort of quality resources that you could recommend that patients may look to either on the internet or books or anything? Oh, gosh, that's a good question.

I would say ABORM, like I've said before, is a great organization to look into. There's a database of acupuncturists all across the country and internationally on there that people can find a fertility focused acupuncturist. In terms of naturopathic medicine, there's the California Association of Naturopathic Doctors.

So calnd.org is I believe the website that has a database of naturopathic doctors in California. There's the AANP, which is the American Association of Naturopathic Physicians, which also is maybe more national association for the U.S. It's not going to be fertility specific for either of those groups, but at least it will help you find a licensed naturopathic doctor because there are, depends on your state. Some states do not license naturopathic doctors.

And so you might have someone who's a, they might call themselves a naturopath and they actually haven't gone to a four-year medical training program. They understand that like an online coaching program. So I know it gets a little political and dicey, but I would say if you're in a state that doesn't license naturopathic doctors, definitely go to the AANP and do your research and find someone that's been to one of the accredited schools.

Great. Well, Dr. Rarig, thank you so much for joining us today to talk about complementary and integrative medicine and infertility treatment. We appreciate all your insights today.

Again, my name is Brooke Rossi and I am an REI practicing in Columbus, Ohio, and thank you so much for joining us for the SART Fertility Experts Series. Thank you. The information and opinions expressed in this podcast do not necessarily reflect those of ASRM and its affiliates.

These are provided as a source of general information and are not a substitute for consultation with a physician.