Chapter 57 Infertility
Aetiology
Constitutional weakness
Constitutional weakness of the Kidney-Essence is an important cause of infertility. Such weakness may be due to the woman’s mother having been too old when conceiving her, the parents’ constitution being not good, the parents’ health being not good at the time of conception, etc. Because the Kidney-Essence is the basis for the Tian Gui, the woman cannot conceive.
Overwork
Overwork in the sense of working long hours without adequate rest and with irregular diet for years is a major cause of Kidney-Yin deficiency. Kidney-Yin is the basis for menstrual blood and the uterus and when it is deficient there may be infertility.
Excessive physical work
Excessive physical work or strenuous exercise and sports weaken the Spleen- and Kidney-Yang, especially at puberty time when a young girl’s uterus is in a vulnerable state. At this age, excessive physical work may take the form of playing too much sport, training too hard at ballet or gymnastics, working on a farm, etc.
Sexual activity at too early an age
Sexual activity at too early an age (i.e. before and during puberty and up to about 18) is an important and increasingly frequent cause of disease in Western countries. It seriously weakens the Kidneys and damages the Directing and Penetrating Vessels (Ren and Chong Mai) and may therefore cause infertility later in life.
Invasion of Cold
Invasion of Cold is a very common cause of infertility in young women – indeed, probably the most common cause of primary infertility in young women. If a girl undergoing puberty is exposed to cold and dampness (especially during her period) when exercising or playing sports, Cold invades the Uterus, turns into internal Cold and obstructs the Uterus and the Directing and Penetrating Vessels, preventing fertilization.
Irregular diet
Excessive consumption of cold, iced foods and drinks also leads to Cold in the Uterus as above. Excessive consumption of greasy foods and dairy products leads to the formation of Dampness in the Lower Burner which also prevents fertilization. Dampness in the Lower Burner easily turns into Damp-Phlegm which may obstruct the Uterus preventing implantation of the ovum. Blockage of the fallopian tubes is usually due to their obstruction by Damp-Phlegm; however, it is important to note that Damp-Phlegm obstructing the Uterus may cause infertility whether the tubes are blocked or not.
Pathology
When discussing the pathology of infertility, there are various aspects to consider:
Full versus Empty causes of infertility
When diagnosing infertility, we should differentiate clearly between deficiency and excess: this is the most important aspect to clarify. We must diagnose clearly whether the woman cannot conceive because of a lack of Blood and/or Essence (in its Yin or Yang aspect) or because there is a pathogenic factor obstructing the Uterus. On the basis of this diagnosis, we must therefore establish whether we need to tonify and nourish the body’s Qi or to eliminate pathogenic factors.
Empty conditions
In case of Empty conditions, infertility is due to a lack of the vital substances that are essential for conception, i.e. Blood and/or Essence. The two main deficiencies are those of Blood or of Kidneys (which may be Kidney-Yin or Kidney-Yang).
Whether it is a deficiency of Kidney-Yin or Kidney-Yang, the Kidney-Essence is always involved in its Yin or Yang aspect. As discussed in Chapter 2 on physiology, the menstrual function and the Uterus rely on the Yin aspect (which is Post-Natal) and on the Yang aspect of the Essence (which is Pre-Natal). The Yang aspect of the Essence is the Fire of the Gate of Life, also called the Minister Fire, that is formed at conception.
As we have seen in Chapter 2, the Minister Fire is of a special type: a ‘formless’ Fire, it can actually generate Water (rather than drying it up). For fertilization to occur, the Yin and Yang aspects of the Essence need to be perfectly balanced: the Yin in the form of Water, Essence and Blood is the substantial basis for conception to occur, but the Yin needs the warming and fertilizing action of Yang, in the form of Minister Fire.
If the Water, i.e. the Yin aspect, is deficient, there is not enough nourishment to support the fertilized egg (or to produce an egg at all); if the Minister Fire is deficient, there is no ‘spark’ to transform and activate the Water, which therefore cannot fertilize or nourish an egg. Vice versa, if the Minister Fire is excessive and pathological, the Blood in the Uterus may become hot and this creates adverse conditions for the fertilization or support of an egg. Figures 57.1 and 57.2 illustrate these concepts.
Full conditions
In the case of Full conditions, fertilization cannot occur because pathogenic factors obstruct the Uterus and the Directing and Penetrating Vessels (Ren and Chong Mai). Such pathogenic factors may be Cold (very common in cold and damp countries), Blood-Heat, Dampness, stagnation of Qi, stasis of Blood and Phlegm. Fertilization is a very delicate process fraught with difficulties and any of the above pathogenic factors may prevent it.
Cold is a very frequent cause of infertility: it prevents conception by obstructing the Uterus and its channels. As we have just seen, the Fire of the Gate of Life is essential for the fertilization of the egg: the Essence, in its Yin aspect, provides the basis for conception by producing the eggs, but the Fire of the Gate of Life is essential for the transformation of the egg into a fetus. Cold obstructs the Uterus and dampens the Fire of the Gate of Life, preventing fertilization. Cold can be of the Full or Empty type, depending on how much Kidney-Yang deficiency there is. One of the most important diagnostic factors differentiating Full- from Empty-Cold is the pulse: in Full-Cold the pulse will be Full and Tight, while in Empty-Cold it will be Weak on the whole (although it may also be slightly Tight on the left Rear position).
Blood-Heat also causes infertility, but in the opposite way. Blood and Essence are the basis for conception (the Uterus is also called the Blood Chamber). Thus, if the Blood is hot it may create adverse conditions for the fertilization of the egg. The influence of Cold and Blood-Heat can be compared with a bird’s incubation of an egg; the temperature should be steady, warm, neither too cold nor too hot.
Dampness, to which women are particularly prone, invades the body from the Lower Burner. It prevents the proper movement of Qi and Blood and may therefore lead to stagnation of Qi and/or stasis of Blood. Unable to function properly, the Directing and Penetrating Vessels (Ren and Chong Mai) cannot gather the Essence for the woman to conceive. From a channel perspective, this may due also to a pathology of the Girdle Vessel (Dai Mai) affecting the Directing Vessel (see Ch. 7). From a Western perspective, Damp-Heat often corresponds to pelvic or tubal inflammation.
Blood stasis is a frequent cause of infertility: stagnant Blood obstructs the Uterus and its channels and it prevents the proper functioning of the Directing and Penetrating Vessels so that conception cannot occur. If Blood stasis is severe and longstanding, stagnant Blood can give rise to abdominal masses, endometriosis, ovarian cysts or myomas. In endometriosis, a major factor in infertility, there is always Blood stasis.
Phlegm may cause infertility by obstructing the Uterus and its channels so that the Directing and Penetrating Vessels cannot function properly and the Essence cannot be gathered. Zhu Dan Xi (1281–1358) says in his The Heart and Essence Dan Xi’s Methods of Treatment: “Inability to conceive in fat women is caused by the Fat [i.e. Phlegm] within the body blocking the Uterus.”1 This is an interesting statement because polycystic ovary syndrome, a major cause of infertility, often occurs in obese women. Modern Chinese doctors relate obesity to Phlegm. Damp-Phlegm is nearly always the main pathogenic factor in polycystic ovary syndrome.
The Directing and Penetrating Vessels in infertility
No matter whether the condition is Full or Empty, in infertility the Uterus and the Directing and Penetrating Vessels (Ren and Chong Mai) are obviously always involved. In case of deficiency, the Uterus and the Directing and Penetrating Vessels lack the necessary nourishment to nurture the fertilized egg or to produce an egg at all; in the case of excess, pathogenic factors obstruct these structures and prevent their proper Qi, Blood and Essence transformation so that fertilization or implantation cannot occur (Fig. 57.3).
Treatment of the Penetrating and Directing Vessels is essential in infertility whether in a Full or Empty condition. In Empty conditions, Ren-4 Guanyuan is the best point to use: it nourish Blood, tonifies the Kidneys (both Yin and Yang), nourishes the Essence, strengthens the Original Qi (Yuan Qi); finally, it strengthens both the Directing and the Penetrating Vessels because the latter connects with it internally. In Empty conditions, I often combine Ren-4 with KI-13 Qixue (a point of the Penetrating Vessel).
In Full conditions, the best points to use are Ren-3 Zhongji and KI-14 Siman (a point of the Penetrating Vessel).
The cervical secretion
When treating infertility, one must always take into consideration the cervical secretion that occurs just before ovulation and that indicates fertility. As discussed in Chapter 2, the cervical secretion is a direct manifestation of Kidney-Essence and its absence (or short duration of 1 day only) indicates a deficiency of Kidney-Essence and a weakness of the proliferative phase. Therefore, one must always ask a woman seeking treatment for infertility to check the cervical secretion every month.
The basal body temperature
The second sign that one must consider is the basal body temperature (BBT) also discussed in Chapter 2. Although the BBT does not give us indications for treatment as the spike in temperature occurs after ovulation, it is important to chart the temperature every month to monitor the progress (or lack of it) of the treatment. If a previously flat chart starts to develop the typical biphasic shape, it is obviously a very good sign. It is also very encouraging for the patients to see the objective improvement in the chart for themselves.
Connections with biomedical causes of infertility
Although it is not possible to make direct connections between Western pathologies and Chinese medicine patterns, modern Chinese books and journals make such an endeavour. Although one should keep an open mind and rely on a Chinese diagnosis and identification of patterns for treatment, such connections can give broad guidelines. According to such modern connection, absence or irregularity of ovulation often corresponds to a Kidney deficiency; blockage of the fallopian tubes to Damp-Heat, possibly with Toxic-Heat and stasis of Blood; uterine myomas and endometriosis to stasis of Blood, possibly with Phlegm; and pelvic adhesions to Dampness with stasis of Blood.
Patterns of infertility
To get an idea of the statistical incidence of each type, we may refer to a study of 257 cases of infertility reported in Beijing’s Journal of Chinese Medicine.2 Of these 257 cases, the following were the proportions of various patterns:
As can be seen, if we total up all the various types of Kidney deficiency we obtain a total percentage of 57.20% of Kidney-Deficiency cases, by far the highest one. However, these figures are related to Chinese conditions and may not be exactly the same in other countries. For example, one might infer that the percentage of cases due to Cold and Dampness would be higher not only in cold and damp climates but also in relatively warm countries due to the consumption of iced drinks, especially by young people. Also, in my experience, the percentage of cases of infertility due to Phlegm would be considerably higher.
Identification of patterns and treatment
Infertility is frequently treated in China according to the four phases of the menstrual cycle as described in Chapter 2, i.e. the period, the post-menstrual, the inter-menstrual and the pre-menstrual phases. The treatment principles in each phase are as follows:
In relation to infertility in particular, the treatment principle can be slightly different because the emphasis is always put on the treatment of the Kidneys (especially in deficiency conditions). Also, the phases are sometimes slightly different, being defined more according to Western physiology. For example, Dr Li Xiang Yun defines the following four phases:
Dr Li recommends the following treatment principles for the above four phases:
The treatment of infertility according to the four phases is always based principally on treating the Kidneys because the phases are a result of the waxing and waning of Kidney-Yin and Kidney-Yang and because the Kidneys are the source of the Tian Gui which is the basis for reproduction. Thus, from a Western perspective, the follicle maturation, ovulation, the ova and the corpus luteum are all manifestations of the fluctuation of Kidney-Yin and Kidney-Yang during the menstrual cycle. For this reason, several of the prescriptions mentioned in this chapter are based on four different formulae according to the above four phases of the menstrual cycle and they are all aimed at establishing a regular menstrual cycle and ovulation by tonifying different aspects of the Kidneys at each different phase.
From an acupuncture perspective, the Governing, Directing and Penetrating Vessels (Du, Ren and Chong Mai) are the basis for follicle maturation, ovulation and corpus luteum development and these channels should therefore always be used to treat infertility. The Directing and Penetrating Vessels are Yin in nature and represent the biological basis for the follicles, ova and corpus luteum, while the Governing Vessel, Yang in nature, is the force of transformation that assists the biological processes involved in fertilization, i.e. the maturation of follicles, the expulsion of the ova and the maturation of the corpus luteum.
The patterns discussed are as follows:
Combined patterns
Please note that although the patterns are discussed individually, in practice they will always occur in combination. For example, it is very common for a woman with infertility to suffer from Kidney-Yang deficiency and Dampness (or Damp-Phlegm). It is precisely in these situations that treatment according to the four phases is particularly important.
In the example above of Kidney-Yang deficiency with Dampness, it would be appropriate to tonify Kidney-Yang in phases 2 and 3 and resolve Dampness in phase 4 (or tonify Kidney-Yang in phase 2 and resolve Dampness in phases 3 and 4). For this reason, after discussing individual patterns, I will also discuss some examples of combinations and their treatment. Please note that the patterns given (all with Kidney-Yang deficiency) are only examples: in each case, the woman may be suffering from Kidney-Yin rather than Kidney-Yang deficiency.
Herbs that nourish the Kidney-Essence
Before discussing the differentiation and treatment of infertility, it is useful to review the herbs that nourish the Kidney-Essence. There is no separate category for Essence-nourishing herbs and they can be found in various categories. Most of them are in the Kidney-Yang tonics category. Some of them ‘stabilize’ the Essence rather than nourish it but they are often combined with Essence-nourishing herbs: for example, Bu Gu Zhi Fructus Psoraleae or Yi Zhi Ren Fructus Alpiniae oxyphyllae. ‘Stabilizing’ the Essence implies an astringent action that is used with symptoms such as nocturnal emissions or spermatorrhoea in men and chronic vaginal discharge in women. A list of herbs that nourish the Essence by category is given in Table 57.1
Nourishing the Essence is essential in infertility, especially of the deficient kind, and particularly that from Kidney deficiency. The majority of these cases of infertility are due to an ovulatory dysfunction and ovulation is an expression of the transformation of the Kidney-Essence into ova. Thus, to promote ovulation, it is necessary to nourish the Essence. Nourishing the Essence transcends tonification of Yin or Yang as the Essence itself has a Yin and a Yang aspect. Its Yang aspect is the Minister Fire which is present from conception, and its Yin aspect is the Essence itself that, at puberty, crystallizes into menstrual Blood and the ova (see Fig. 4.3). Given the importance of the role of the Minister Fire in transforming the Tian Gui into menstrual blood and ova, it is interesting to note that the majority of herbs that nourish the Essence are in the Kidney-Yang tonics category. Some of the herbs listed in Table 57.1 deserve particular comment.
Lu Rong Cornu Cervi pantotrichum, Lu Jiao Cornu Cervi, Lu Jiao Jiao Colla Cornu Cervi and Lu Jiao Shuang Cornu Cervi degelatinatum
These are excellent substances to nourish the Essence because they nourish Yang without drying and nourish the Essence at the same time. They also strengthen the Governing Vessel and therefore activate the Minister Fire that promotes the transformation of Kidney-Essence into menstrual blood and ova. Lu Jiao Jiao is particularly indicated for women as it also nourishes Blood, while Lu Jiao Shuang would be indicated when there is excessive menstrual bleeding.
Tu Si Zi Semen Cuscutae
This herb is very frequently used to nourish the Essence and promote ovulation in infertility. Its advantage lies in its rather neutral quality as, although it does tonify Kidney-Yang, its action is rather mild and it can be used to nourish Kidney-Yin.
Herb combinations for infertility
Some herb combinations are used particularly frequently in infertility.
Combinations for deficiency conditions
Tu Si Zi Semen Cuscutae and Gou Qi Zi Fructus Lycii
These are important herbs for Kidney deficiency. The combination is perfectly balanced, being neither too warm or too drying, and it tonifies without cloying. Although this combination tonifies both Yin and Yang, it is primarily for Kidney-Yin deficiency.
Shu Di Huang Radix Rehmannia preparata and Bai Shao Radix Paeoniae alba
This combination tonifies Liver- and Kidney-Yin: it also ‘calms’ and protects the Yin. ‘Calming’ the Yin implies the capacity to stop bleeding from Empty-Heat; ‘protecting’ indicates an ability to prevent leakages of Yin such as occur in persistent vaginal discharges. This combination nourishes Water and irrigates Wood, i.e. it nourishes Kidney-Yin and Liver-Blood.
Shan Yao Rhizoma Dioscoreae and Shan Zhu Yu Fructus Corni
This combination tonifies Liver- and Kidney-Yin: it nourishes also the Kidney-Essence. Neither too hot nor too drying, it tonifies without creating stagnation: it can tonify as well as astringe.
Rou Cong Rong Herba Cistanches and Ba Ji Tian Radix Morindae officinalis
This is an important combination for infertility from deficiency. These two herbs in combination enter the Governing Vessel and they are often combined with Qi and Blood tonics when there is Kidney-Yang deficiency. The characteristic of this combination is to promote transformation by the warming action of Yang but, at the same time, to nourish the Essence. These two herbs are often combined with Yin tonics to nourish the Yin and Yang aspect of the Essence and promote fertility. In such a case, Bai Zi Ren Semen Platycladi is often added to the Yin tonics to nourish Yin, tonify Blood and moisten the Intestines.
Fu Pen Zi Fructus Rubi and Zi Shi Ying Fluoritum
This combination is often used in deficiency-type infertility: it warms without drying and it tonifies Yin within Yang. It tonifies the Kidneys and the Essence.
Zi He Che Placenta hominis and Lu Jiao Cornu Cervi
This combination tonifies Spleen- and Kidney-Yang and nourishes the Essence. Both animal products, they are used according to the two principles that ‘animal products have feeling’ and ‘animal products nourish the Governing, Directing and Penetrating Vessels’. The combination is sweet, salty, warming and nourishing, it strengthens the Uterus and nourishes the Governing, Directing and Penetrating Vessels.
Ba Ji Tian Radix Morindae officinalis and Lu Jiao Cornu Cervi
This combination tonifies Spleen- and Kidney-Yang. Like the above combination, it nourishes the Governing, Directing and Penetrating Vessels; it warms and tonifies the Directing and Penetrating Vessels, nourishes the Kidneys and benefits Yang.
Xian Mao Rhizoma Curculiginis and Yin Yang Huo Herba Epimedii
This combination is pungent and hot and it tonifies the Fire of the Gate of Life. It is frequently used for infertility from pronounced Kidney-Yang deficiency with ovulatory irregularity. Obviously it should not be used in Yin deficiency as both herbs are very hot.
Dang Shen Radix Codonopsis and Huang Qi Radix Astragali
This combination tonifies and raises Qi. Apart from its use in prolapse, it is used for corpus luteum defect. These two herbs are often combined with Kidney-Yang tonics.
Combinations for excess conditions
Chai Hu Radix Bupleuri and Yan Hu Suo Rhizoma Corydalis
This combination is used for pelvic inflammation and fallopian tube obstruction. These two herbs in combination pacify the Liver, move Qi, eliminate stagnation and stop pain. They are specific to remove or prevent obstructions.
Pu Gong Ying Herba Taraxaci and Hong Teng Caulis Sargentodoxae
This combination can treat acute pelvic inflammation and tubal obstruction. Bitter and cold, these herbs clear Heat, resolve Toxic-Heat, dissipate nodules and dissolve swelling. They are often combined with Bai Jiang Cao Herba Patriniae to enhance their stasis-eliminating and nodule-dissipating effect.
Chuan Lian Zi Fructus Toosendan and Lu Lu Tong Fructus Liquidambaris
This combination can be used for tubal obstruction: it moves Liver-Qi and invigorates Blood.
Lu Lu Tong Fructus Liquidambaris and Di Long Pheretima
This combination can be used for tubal obstruction and hydrosalpinx (accumulation of watery fluid in the fallopian tubes). The herbs clear Heat, transform Water and remove obstructions from the Connecting channels.
Ma Bian Cao Herba Verbenae and Wang Bu Liu Xing Semen Vaccariae
This combination can also be used for hydrosalpinx: it invigorates Blood, removes obstruction from the Connecting channels and transforms Water. These herbs are often combined with Shi Jian Chuan Herba Salviae chinensis.
Xiao Hui Xiang Fructus Foeniculi and Chen Xiang Lignum Aquilariae resinatum
This combination can be used for tubal obstruction occurring against a background of Cold. The herbs move Qi, remove obstructions from the Connecting channels, warm the Kidneys and scatter Cold. Pungent and warm, they may therefore injure Yin: for this reason, they should not be used for longer than 5 days at a time.
Shi Chang Pu Rhizoma Acori tatarinowii and Dan Nan Xing Rhizoma Arisaematis preparatum
This combination can be used for infertility from Dampness and Phlegm. These two herbs resolve Phlegm, open the orifices, arouse the brain and remove Dampness and Phlegm from the Connecting channels. If there is a pronounced Cold condition, these herbs are often combined with Shi Nan Ye Folia Photiniae serrulatae.
Shi Jian Chuan Herba Salviae chinensis and Liu Ji Nu Herba Artemisiae anomalae
This combination can be used for pathological changes of the endometrium and ovarian cysts. The herbs clear Heat, transform Water, remove obstructions from the Connecting channels and dissipate nodules.
Pu Huang Pollen Typhae and Chi Shao Radix Paeoniae rubra
This combination can be used for pathological changes of the endometrium: the herbs invigorate Blood, eliminate stasis and cool Blood.
San Leng Rhizoma Sparganii and E Zhu Rhizoma Curcumae
This combination can be used for pathological changes of the endometrium. These herbs ‘break’ Blood, eliminate stasis, move Qi and stop pain. Since they ‘break’ Blood, they may injure the Original Qi and should therefore be used sparingly.
Ru Xiang Olibanum and Mo Yao Myrrha
This combination can be used for pathological changes of the endometrium. These herbs invigorate Blood, eliminate stasis, dissolve swelling and stop pain: they affect both Qi and Blood.
Xue Jie Resina Daemonoropis and San Qi Radix Notoginseng
This combination can be used for pathological changes of the endometrium. These herbs both remove obstruction and stop fluid and blood leakage; they invigorate Blood, eliminate stasis, stop pain and arrest bleeding.
Sang Ji Sheng Ramulus Sangjisheng and Si Gua Luo Retinervus Luffae fructus
This combination can be used for obstruction of the Fallopian tubes. The herbs tonify Liver and Kidneys but also remove obstructions from the Connecting channels. They are often combined with Sang Zhi.
Empty conditions
Kidney-Yang deficiency
Clinical manifestations
Prolonged menstrual cycle, the period could be either scanty or heavy, backache, dizziness, feeling cold, depression, frequent urination. Tongue: Pale, wet. Pulse: Deep, Weak.
Treatment principle
Tonify and warm Kidney-Yang, stoke up the Fire of the Gate of Life, strengthen the Uterus.
Acupuncture
KI-13 Qixue, KI-3 Taixi, BL-23 Shenshu, BL-52 Zhishi, Ren-4 Guanyuan, Du-4 Mingmen, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Ren-8 Shenque-Baomen, Zihu. All with reinforcing method; moxa should be used.
Explanation
Special moxibustion prescription
A special moxibustion method for infertility from Kidney-Yang deficiency consists in using moxa on Ren-8 Shenque. The method is as follows: take 2.5 g of moxa wool and add 1 g each of powdered Chuan Jiao Pericarpium Zanthoxyli and Xi Xin Herba Asari, and wet the mixture with a saline solution. Make into a paste. Place this paste in the umbilicus, cover with a thin slice of fresh ginger and apply moxibustion to it with a moxa stick for 30 minutes. After that, leave the paste in the umbilicus, cover with a plaster and remove after 24 hours. Repeat the same procedure for 10 successive days.6
Herbal treatment
a. Prescription
Explanation
The first 12 herbs constitute the formula Yu Lin Zhu which tonifies Kidney-Yang and promotes fertility. The unicorn is a symbol of fertility, hence the name of the formula which means ‘giving birth to the unicorn pearl’. It is from the Complete Works of Jing Yue (Jing Yue Quan Shu, 1624).
b. Prescription
Explanation
The first nine herbs constitute the formula Ba Zhen Yi Mu Tang which tonifies Qi and Blood and invigorates Blood. This formula is particularly indicated if, in addition to a deficiency of Kidney-Yang, there is a pronounced deficiency of Blood.
c. Prescription
Explanation
This formula is particularly indicated if there is a pronounced deficiency of Kidney-Essence: with regard to infertility, this would manifest with absent or irregular ovulation.
d. Prescription
This prescription consists of two formulae, one to be taken for 7 days after the period and the other for 8 days during ovulation.
Formula I (for 7 days after the period)
Formula II (for 8 days during ovulation)
Table 57.2 compares and contrasts the formulae for infertility from Kidney-Yang deficiency.
Women’s Treasure remedy
This remedy tonifies Kidney-Yang, nourishes Blood and Essence and strengthens the Governing Vessel. The tongue presentation appropriate to this remedy is a Pale and wet tongue.
Kidney-Yang deficiency
Clinical manifestations
Prolonged menstrual cycle, the period could be either scanty or heavy, backache, dizziness, feeling cold, depression, frequent urination. Tongue: Pale, wet. Pulse: Deep, Weak.
Treatment principle
Tonify and warm Kidney-Yang, stoke up the Fire of the Gate of Life, strengthen the Uterus.
Acupuncture
KI-13 Qixue, KI-3 Taixi, BL-23 Shenshu, BL-52 Zhishi, Ren-4 Guanyuan, Du-4 Mingmen, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Ren-8 Shenque-Baomen, Zihu. All with reinforcing method; moxa should be used.
A 35-year-old woman had been trying to conceive for 2 years. Her periods were regular but scanty, lasting only 2 days. The menstrual blood was bright red and there were no clots. She also complained of dull headaches on the vertex, floaters and dizziness. On interrogation, it transpired that she had also suffered from allergic rhinitis since the age of 17, manifesting with sneezing attacks and a clear, watery nasal discharge. She also complained of backache, occasional tinnitus, feeling cold in general and cold feet. Her tongue was slightly Pale and Swollen with a Heart crack, and her pulse was Weak on both Rear positions and slightly Choppy in general. Her complexion was dull and pale.
Diagnosis
There are two main patterns: one is Blood deficiency and the other Kidney-Yang deficiency. The symptoms of Blood deficiency are dull and pale complexion, floaters, scanty periods, dull headaches on the vertex, Choppy pulse and Pale tongue. The manifestations of Kidney-Yang deficiency are feeling cold, cold feet, occasional tinnitus, Weak Kidney pulses and Swollen tongue. I relate allergic rhinitis also to a Kidney-Yang deficiency and specifically a deficiency of what I call ‘Kidney Defensive Qi system’ (see Ch. 6 of the Practice of Chinese Medicine8). From a channel point of view, allergic rhinitis also involves a weakness of the Governing Vessel, which is consistent with a deficiency of Kidney-Yang. On the other hand, the Blood and Kidney-Yang deficiency involves a deficiency of the Directing and Penetrating Vessels: thus, in her case, there is a deficiency of the three main Extraordinary Vessels that control fertility, conception and pregnancy.
Treatment principle
This patient was already receiving acupuncture and had been referred by her acupuncturist: I therefore treated her only with herbs. I used a variation of Yu Lin Zhu Fertility Pearl:
Explanation
After one course of this prescription (1 month) she felt better in general and the rhinitis got better as well. I continued treating her with similar prescriptions for 7 months after which she became pregnant. As she had quite a severe deficiency of Blood and Kidney-Yang, I treated her during the first few months of pregnancy to prevent miscarriage with a simple formula to tonify Kidney-Yang and ‘calm the fetus’:
Because I usually prefer not to give herbs in the first 3 months of pregnancy at all, I kept the number to a minimum. I chose the above three herbs, using 6 g each, because they would address her two main deficiencies and calm the fetus, i.e. prevent miscarriage. After 9 months, she gave birth to a healthy baby.
A 35-year-old woman had been trying to conceive for 2 years. She had conceived but miscarried 3 months previously. Her periods were regular, they lasted 4–5 days and the menstrual blood’s colour was normal. She often felt cold, especially in her feet. She also tired easily and occasionally suffered from headaches. Her tongue was of a normal colour, except for being Red on the tip and sides, and the tongue body was Thin. Her pulse was Weak on both Rear positions and relatively Overflowing on the left Front position.
Diagnosis
Although there are few symptoms, we can diagnose a Kidney-Yang deficiency from the general cold feeling, cold feet, tiredness, the infertility itself, the miscarriage and the Weak pulse on both Kidney positions. The Kidney deficiency has given rise to some Liver-Yang rising (headaches and Red sides of the tongue) and Heart-Fire (Red tip of the tongue and Overflowing Heart pulse).
Treatment principle
The treatment principle adopted was to tonify and warm Kidney-Yang, promote fertility and clear Heart-Fire. I treated her with acupuncture and a prepared remedy first, then a decoction.
Explanation
The first 10 herbs constitute the original formula by Dr Shang Xian Min, minus Zi He Che Placenta hominis and Fu Pen Zi Fructus Rubi.
I treated her for 4 months with this formula, at the end of which she became pregnant. Since she had had a miscarriage, I treated her during the first 3 months with the following herbs which prevent miscarriage:
I chose Huang Qin among the fetus-calming herbs because of her pre-existing Heart-Fire and Du Zhong because of the Kidney-Yang deficiency. The other two herbs also calm the fetus to prevent miscarriages. After 9 months, she gave birth to a healthy baby.
Kidney-Yin deficiency
Clinical manifestations
Long-term infertility, periods early, scanty, with light-coloured blood, five-palm heat, night sweating, dizziness, tinnitus. Tongue: without coating; also Red if there is Empty-Heat. Pulse: Floating-Empty or Rapid-Fine (in case of Empty-Heat).
Acupuncture
Ren-4 Guanyuan, Ren-7 Yinjiao, KI-3 Taixi, KI-13 Qixue, SP-6 Sanyinjiao, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), BL-52 Zhishi. All with reinforcing method; generally speaking, no moxa should be used. However, if the tongue is not Red or only slightly Red and the pulse is very Fine, a small amount of moxa (as a warm needle) on KI-3 is beneficial to increase the tonifying effect.
Herbal treatment
a Prescription
b Prescription
Explanation
Compared with the previous formula, the present one is better at clearing the Empty-Heat that arises from Yin deficiency: it is therefore suitable when the tongue is particularly Red.
c. Prescription
Explanation
Dr Zhu Nan Sun places the emphasis very much on Kidney-Yang for the treatment of infertility and he therefore uses Kidney-Yang tonics even in Yin-nourishing formulae. The formula reflects this approach with the inclusion of Rou Cong Rong and Ba Ji Tian. Compared with the previous two formulae, the present one is better when there is a combined deficiency of Kidney-Yin and Kidney-Yang, albeit with a predominance of Kidney-Yin deficiency.
Women’s Treasure remedy
This remedy nourishes Kidney-Yin, Kidney-Essence and Blood and strengthens the Directing and Penetrating Vessels. The tongue presentation appropriate to this remedy is a Red body without coating.
Kidney-Yin deficiency
Clinical manifestations
Long-term infertility, periods early, scanty, with light-coloured blood, five-palm heat, night sweating, dizziness, tinnitus. Tongue: without coating; also Red if there is Empty-Heat. Pulse: Floating-Empty or Rapid-Fine (in case of Empty-Heat).
Acupuncture
Ren-4 Guanyuan, Ren-7 Yinjiao, KI-3 Taixi, KI-13 Qixue, SP-6 Sanyinjiao, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), BL-52 Zhishi. All with reinforcing method; generally speaking, no moxa should be used. However, if the tongue is not Red or only slightly Red and the pulse is very Fine, a small amount of moxa (as a warm needle) on KI-3 is beneficial to increase the tonifying effect.
Blood deficiency
Clinical manifestations
Scanty periods, pale blood, delayed cycle, tiredness, depression, dizziness, pale complexion, blurred vision. Tongue: Pale and Thin. Pulse: Choppy or Fine.
Acupuncture
Ren-4 Guanyuan, ST-36 Zusanli, SP-6 Sanyinjiao, KI-13 Qixue, BL-20 Pishu, BL-23 Shenshu, BL-17 Geshu, abdomen Zi Gong (three cun lateral to Ren-3). All with reinforcing method; moxa is applicable.
Herbal treatment
Women’s Treasure remedies
This remedy is a variation of the formula Ba Zhen Tang Eight Precious Decoction which nourishes Blood. The tongue presentation appropriate to this remedy is a Pale and Thin body.
Blood deficiency
Clinical manifestations
Scanty periods, pale blood, delayed cycle, tiredness, depression, dizziness, pale complexion, blurred vision. Tongue: Pale and Thin. Pulse: Choppy or Fine.
Acupuncture
Ren-4 Guanyuan, ST-36 Zusanli, SP-6 Sanyinjiao, KI-13 Qixue, BL-20 Pishu, BL-23 Shenshu, BL-17 Geshu, abdomen Zi Gong (three cun lateral to Ren-3). All with reinforcing method; moxa is applicable.
A 33-year-old woman had been trying to conceive for 4 years. She had been told that her failure to conceive was due to an ovarian irregularity. She had had IVF treatment twice but both times she miscarried (at 10 and 12 weeks). After her second miscarriage her period did not come for 6 months. Her periods were regular but scanty, lasting only 2 days, with bright red blood. She also complained of constipation and anaemia. Her tongue was Pale and Short and her pulse was Choppy.
Diagnosis
This is a very clear case of Blood deficiency as evidenced by the Choppy pulse, Pale tongue, scanty period and infertility itself. The tongue is Short because the Blood deficiency deprives it of fluids: this makes it less supple and therefore it does not protrude as far as usual. The shortness of the tongue indicates that the Blood deficiency is severe. The fact that the periods did not come for 6 months after her second miscarriage also indicates Blood deficiency.
Explanation
I added a Yin tonic (apart from Gou Qi Zi which is also a Yin tonic) for two reasons: first of all, ‘promoting ovulation’ implies nourishing the Essence and especially its Yin aspect; second, the shortness of her tongue shows that the deficiency of Blood is very severe and is bordering on Yin deficiency.
I treated her with variations of this formula for nearly a year, after which she became pregnant and later gave birth to a healthy baby.
A 32-year-old woman had been trying to conceive for 2 years. She had become pregnant 2 years previously but had a miscarriage at 26 weeks. Her periods were regular and rather heavy, lasting 1 week. There was no pain and the blood was bright red. She also suffered from dizziness and blurred vision. Her tongue was Pale and Swollen and her pulse was Rapid and Empty.
Diagnosis
This is a clear case of Qi and Blood deficiency even though she has few symptoms. Qi deficiency causes her periods to be heavy, the tongue Swollen and the pulse Empty. The Blood deficiency is evidenced by the Pale tongue, dizziness and blurred vision. I interpreted the Rapid pulse as being due to shock: this was apparent also from the look of her eyes which were dull and rather unstable.
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