Introduction

Before any TCM treatment is applied, the doctor must be sure of the diagnosis. By gathering together the relevant details of the case history, and looking at the tongue and taking the pulse, the pieces of the puzzle will usually form a picture which roughly approximates one or more of the patterns outlined in this chapter.

We seldom find a clear-cut textbook case in our clinics. Most women we see in infertility clinics in the West have already run the gauntlet of investigations and treatments – some of them quite invasive – and the diagnostic picture may have been considerably complicated by these. Nevertheless, with time and experience, the TCM doctor learns to sniff out what is relevant and ignore what is not, until a diagnosis and a plan of action can be made, as illustrated in the case histories throughout this book.

The Two Key Elements: Ovulation and Menstruation

Traditionally, the menstrual cycle, and any disturbances of it, were described in Chinese medicine texts only in terms of the period – the arrival (late, early or on time) or the non-arrival of the period – this being the most clearly observable external sign. Thus, observations of the timing and nature of the menstrual flow were the most important signs upon which a diagnosis could be made. Historically, treatments for infertility also gave great emphasis to the period, i.e., treatments were applied during or just before the menstrual flow.

We can now incorporate more modern ideas based on discoveries about female physiology made by Western doctors and scientists, and base our TCM diagnosis on more than just the menstrual flow. We can follow the menstrual cycle not just by the appearance of the period but also by other key events: most importantly the time that the egg is released from the ovary, i.e., ovulation. When we are concerned with fertility this is the key event of the menstrual cycle.

We have at our disposal in the wealthy Western countries extraordinary diagnostic tools which allow us not only to pinpoint the ovulatory event itself but also all the steps leading up to it. For example, a vaginal ultrasound can track the progress of a follicle from the very first signs of stimulation by the follicle-stimulating hormone (FSH) right up to its full size at maturity when the egg will be released. The ultrasound also reveals the readiness (i.e., thickness and structure) of the lining of the uterus to receive a fertilized egg. Blood tests can track ovulation by measuring:

IVF clinics make full and productive use of all these diagnostic tools on a frequent and regular basis, which is one of the reasons these infertility programmes can be so expensive.

However, we do not need to rely on expensive and invasive tests to monitor the internal events of the menstrual cycle. Although not so quantitative in their measurements, careful observation of certain external signs can give us useful qualitative information (Box 4.1).

Taking a History

It makes good sense to start making our TCM diagnosis, and designing treatments, using these physiological signposts as well as subjective descriptions of symptoms. Questions about the period, the middle of the cycle and about sensations in the ovaries, breasts or genitals will offer valuable information. If our patient is recording her BBT, then we can discern even more information about her condition and the diagnosis of her infertility. The shape of the chart, as we saw in Chapter 3, will tell us about the Kidney Yin and Yang and the Qi of the Heart and Liver.

TCM Categories of Female Infertility

At an infertility clinic in the West, we may describe female infertility using such labels as fallopian tube blockage, polycystic ovaries, inadequate luteal phase, oligomenorrhea or irregular, infrequent ovulation, resistant ovary syndrome, endometriosis and so on. Although these disease labels do not usually translate directly into specific TCM categories of infertility, the symptom pictures they manifest are easily analyzed and categorized to fit a TCM diagnostic pattern.

The section on female infertility in traditional TCM gynecology texts is usually found in the last chapter as one of ‘eight miscellaneous diseases.’ These texts usually describe four main categories of infertility (and sometimes numerous subcategories), which are given in Box 4.2.

What one sees when prescriptions are handed out to patients in the infertility clinic of the TCM teaching hospital which we visited in Chapter 1, or any other infertility clinic in China, is that nearly all the prescriptions treat the Kidneys. This is not because the last three of the four patterns described in Box 4.2 do not occur in practice but because they usually occur in combination with, or even as a result of, a Kidney weakness. If there is functional infertility, then by definition the Kidney Yin and Yang are depleted or not functioning correctly.

The categories of functional female infertility could be rewritten (Box 4.3):

We know there is no (or rare) ovulation if:

We know there is ‘poor’ ovulation if:

We suspect problems with implantation if:

The following are general clinical pictures. It is important to remember when making a diagnosis that not all women who suffer from a particular deficiency or stagnation will show all (or even some) of the described symptoms and signs. Every case will manifest a different constellation, depending on where the deficiency or stagnation exerts its influence most.

Same Disease, Different Treatments

In Chinese medicine there is a saying:

which means:

For example, in the clinic we may see four women all with polycystic ovary disease. But these women’s clinical presentation may reflect four different types of TCM diagnosis and therefore four different treatment plans. Three women, on the other hand, who suffer variously from amenorrhoea, menstrual headaches or dysmenorrhea may all receive the same basic TCM diagnosis and be treated using small variations of the same guiding herbal prescription. The treatment of many and diverse women arriving at the fertility clinic likewise will proceed according to their TCM diagnosis and despite the common label ‘infertility’ they will all receive different individualized treatments. Modern innovations to TCM treatments come from the information we receive about particular events in the menstrual cycle using blood tests, ultrasounds, BBT measurements or cervical mucus examination.

Wide fluctuations in Qi and Blood and Yin and Yang occur during the menstrual cycle, resulting in different imbalances manifesting at different times. Two of the most obvious examples, often seen in the clinic, are Blood deficiency after the period and Liver Qi stagnation before the period. We now know that Kidney Yin deficiency affects, in particular, the processes of the first phase of the cycle, and Kidney Yang deficiency affects, in particular, the processes of the second phase of the cycle. So, naturally, our diagnosis and the emphasis of treatment changes at different times of the cycle – this is why the treatment of women is considered so much more complex than that of men.

In Chinese medicine texts, the Kidney is said to ‘dominate reproduction’ – the Kidney Yin and Yang must be adequate and balanced for the correct functioning of all aspects of the female (and male) reproductive organs. Consequently, the treatment of Kidney Yin and Yang underpins all Chinese medicine prescriptions for infertility. The exception to this rule is infertility caused by simple obstruction in the reproductive tract with no impairment of gland function. A young woman with blocked fallopian tubes (possibly a result of a non-symptomatic chlamydia infection years earlier) will often fall pregnant very easily once the obstruction is removed (surgically) or circumnavigated (by IVF procedures).

When it comes to treating infertility, or any other gynecologic disorder, no matter what our diagnosis, it is important to always keep the treatments congruent with the phase and stage of the menstrual cycle during which it is being administered. This means following closely the relative activities of the Chong and the Ren vessels and the relative balance of Kidney Yin and Yang.

Prescribing Treatment

In this chapter, I present a few guiding formulas and acupuncture treatments which can be applied at different times of the menstrual cycle and which can be modified to make them uniquely fitting for the individual patient. The herbal formulas presented here – all of them used by doctors working in infertility clinics in China today – are age-old century-tested medicines applied according to diagnoses arrived at using the traditional Bian Zheng (or pattern recognition) methods of TCM in combination with modern diagnostic methods.

Sometimes, Western drug therapy is appropriate alongside herbal or acupuncture treatment. This will be mentioned briefly here and in the following chapter, which looks at Western disease categories of infertility. The combination of IVF and other assisted reproduction technology (ART) with Chinese medicine is covered in Chapters 10 and 11. Lifestyle and dietary changes are often crucial too (see Ch. 12). Any practitioner can follow the simple approach outlined in this chapter. Simple prescribing, however, does not mean simplistic. Many very skillful and experienced doctors use simple classical formulas – the skill comes in the timing of their administration and the adjustments that are made to account for individual nuances in the presenting pattern. With experience, specialists in infertility refine their prescriptions elegantly and subtly.

The most useful way to approach prescribing, for practitioners new to this area, is to choose an appropriate guiding formula and then customize it to fit the patient. For example, because we are treating the reproductive system the classical formula Liu Wei Di Huang Wan, which supplements Kidney Yin, will turn up time and time again, but will be modified to suit different patients and the stage of the menstrual cycle.

The treatments presented here are only one set of possible guidelines – historically, there were many approaches taken by infertility doctors, who each developed their own favorite protocols. The following treatments are based on those developed by Professor Xia Gui Cheng from the Jiangsu Province Hospital in Nanjing.¹ They represent one of the more rational and consistent approaches to the treatment of infertility in women, comprising sound, well-tested and proven strategies based on both Chinese medicine and Western medicine knowledge.

Chinese herbs are not always very convenient (or palatable) for Western women, and for those women who have difficulty taking them in decoction there are good alternatives. Responding to a demand by Western consumers for ‘convenient’ medicines, and increasingly by Chinese patients themselves, factories in China are now producing quality controlled ‘instant’ preparations of individual herbs which appear to retain a high degree of potency. These granulated herbs can be mixed up into prescriptions which are then dissolved in boiling water to make a ready-to-drink tea, reducing preparation time significantly. And for patients who really cannot tolerate the taste, the granules can be put in capsules.