This article is largely a summary of two fantastic seminars: The 2008 Health World TCM Seminar “The Treatment of Sub-fertility with TCM”, presented by Jan McLay and the 2004 Sun Ten Chinese Medicine Pearls Seminar “Treatment of Infertility (Male and Female)” by Professor Guo Zhi Qiang, interpreted by Dr. Greta Young Jie De, seminar manuals and information are available from Greta Young Jie De.
The Treatment of Sub-fertility with TCM
What Do We Mean By the Term ‘Infertility’?
In Western medical terms, infertility is defined as an inability to conceive after at least 12 months of unprotected sex. However, much of what is diagnosed as ‘infertility’ could be more accurately described as ‘sub-fertility’. According to Jan McLay, true infertility is often associated with either a complete lack of sperm (i.e. azoospermia) or ovaries which produce no eggs despite medical intervention.
Jan has seen many patients who have been diagnosed with ‘unexplained infertility’ after going through cycles of assisted reproductive technology (ART) with no success; however this may not indicate that they are truly infertile. Jan has found that if a body is capable of producing gametes (i.e. ova or sperm), then the problem is not true infertility; rather the difficulty in achieving conception lies in making those gametes come together to create a viable embryo, and making certain that the embryo implants properly and proceeds to a viable pregnancy.
The Menstrual Cycle in TCM Terms - The Yin Phase
The yin phase refers to the first half of the menstrual cycle from day one of the period through to ovulation, which is known as ultimate yin. In biomedical terms, the yin phase is referred to as the follicular phase or the proliferative phase of the cycle, based on two vital processes that occur during this half of the cycle: ripening of follicles and the eggs therein, and the proliferation of the uterine lining. Day one of the menstrual cycle, the first day of bleeding, indicates the switch from yang to yin, with the shedding of the endometrial lining which will not be needed to support a pregnancy. Simultaneously, new messages are sent to the ovary to begin the cycle anew.
During the menstrual period, any obstructions to the movement of qi and blood will manifest as pain and/or the presence of clots or tissue-like substance in the menstrual flow. These signs tell the Practitioner there are problems with qi and blood stagnation, and possibly with the integrity of the uterine lining. The chong vessel is completely emptied during the menstrual period. After menstruation, treatment is focused on re-building the yin and blood, so that the chong vessel is once again replenished. During this time, a diet aimed at building and nourishing the blood should form an important part of the treatment strategy. Yin and blood tonics are routinely begun on day four of the menstrual cycle, however, yin tonics may be used throughout the entire cycle and during the menstrual period in women who are extremely yin deficient.
From the TCM perspective, the growth of yin during the follicular phase can be demonstrated by sufficient levels of follicle stimulating hormone (FSH). FSH acts on the dominant follicle to stimulate development and maturation of the egg, a process which can be supported with Chinese Medicine. While the actual DNA of the egg cannot be altered by yin tonics, the quality of the egg and size of the follicle can indeed be improved. With the hormonal changes that occur prior to and following ovulation, there will also be a change in the quality and quantity of the cervical mucus. The increase in oestrogen during the follicular phase affects the glands of the cervix, stimulating them to produce copious amounts of fertile mucus which can be seen as a clear, wet and slippery mucus.
This change in cervical mucus allows sperm passage through the cervix into the uterus in order for fertilisation to take place.
The Switch from Yin to Yang
During the follicular phase, oestrogen levels rise and the pituitary releases FSH and lutenising hormone (LH), which triggers ovulation. Ovulation is the release of an egg from the dominant follicle which is then caught by the fimbriae at the end of a fallopian tube. At ovulation the ultimate yin is reached, and the yang phase begins. In order for this process to occur smoothly, the heart qi must remain unobstructed.
From a TCM perspective, this means the bao mai (the vessel between the heart and the uterus) must be open and free from emotional stress in order for ovulation to take place successfully and to allow the sperm to move uninhibited through the cervix to the uterus. Additionally, the channel between the heart and kidneys, the bau luo, may be affected by emotional upset, which can prevent the switch from yin to yang from taking place and result in anovulation.
The Yang Phase
In a healthy cycle, the follicular phase should last for approximately 14 days. Once the egg has been released, the yang phase begins as the remaining parts of the follicle change state to form the corpus luteum. The corpus luteum is vital in the latter half of the cycle, known as the luteal phase, due to its function in producing progesterone. The primary function of progesterone is to support the development of the endometrial lining thereby ‘warming up’ the uterus, and thus establishing a desirable environment for a growing foetus.
Evidence that kidney yang is flourishing can be seen clinically as a rise in basal body temperature (BBT) of around 0.1 to 0.5 degrees, which begins at ovulation. If the luteal phase falls short and the period begins earlier, this suggests an inadequacy of the kidney yang capacity. Fortunately, this is one area that may be rectified through support with TCM. Hindrances to a successful pregnancy include a deficiency of this kidney yang resulting in a ‘cold’ uterus, or endometrial abnormalities such as an inadequate uterine lining or an endometrium that has grown unevenly presenting an inhospitable environment for embryo development.
Endometrial abnormalities may arise due to blood stagnation caused by obstructions such as polyps, fibroids or even scarring from previous surgical procedures. Another problem that may affect the health of the uterus is an excess of fluid or damp on the endometrial surface at the time of attempted implantation. This is thought to be a result of kidney and spleen yang deficiency. As a general rule in fertility issues, yang insufficiency is more easily and successfully treated with TCM and dietary changes than yin deficiency.
How Can TCM Work With Western Medicine?
The more information Practitioners have at their disposal, the more patient-specific treatment they can provide. In addition to the vital TCM diagnosis, it is also extremely useful to have access to the results of biomedical pathology tests. For example:
Blood tests can provide evidence of hormone levels and other general markers of health. Blood tests can be particularly beneficial when working with older patients attempting to conceive. Jan McLay frequently consults with older women undergoing in-vitro fertilisation (IVF) whose blood tests reveal alarmingly high FSH levels, combined with low oestrogen and low progesterone levels. In these cases, Jan attempts to support tired ovaries which are being coerced into responding to IVF stimulating drugs.
Hysteroalpingography (HSG) is a radiologic procedure used to investigate the shape of the uterine cavity and fallopian tubes to detect pathology in these areas. The results of an HSG may be indicative of compromised health of the fallopian tubes, which may be linked with damp, or blood stagnation from scarring.
The Impacts of Assisted Reproductive Technology
In some cases of ART, the doctor may recommend the patient undergoes a ‘down regulation’ treatment cycle. This process involves the use of different medications that effectively override the function of the pituitary in order to suppress a woman’s natural hormone production. Down regulation in turn, has a profound impact on the proper working of the chong and ren. In Jan’s experience, all women who have been diagnosed as being functionally infertile are kidney deficient, and in women whose response to follicle-stimulating medication has been poor (usually older women or those who ovulate sporadically), this kidney weakness can be grossly exacerbated as the already severely compromised ovaries are affected. At times, the damage is irreparable and these women may begin to experience the onset of menopause.
In addition to its physical effects, ART processes are emotionally draining for the majority of women, particularly when they do not achieve the desired result. TCM can be very useful in tackling the inevitable liver and heart qi stagnation associated with this. In fact, Jan incorporates this into her treatment regimen routinely, as in her experience, women who go through ART will inevitably experience some level of emotional volatility.
Caution With Herbs Early in the IVF Cycle
In all but a few cases, Jan does not prescribe Chinese herbs during the first half of an IVF cycle. This is in part because IVF specialists are strongly against any interference at this stage, but also due to the possible risk of complications. One of the major risks associated with combining herbs and follicle-stimulating drugs is the risk of ovarian hyperstimulation, a condition in which patients respond excessively to the IVF drugs and/or the doses given. If ART treatment causes a large numbers of eggs to mature, the high hormone levels combined with the possible increased size of the ovaries may create a potentially life-threatening situation. Adding herbs to the mix is thus inadvisable until a suitable dosing regimen has been established.
Whilst there is a caution with herbal prescribing during this first part of the cycle, acupuncture may be a safe yet effective technique to provide emotional support, enhance drug effectiveness and minimise potential side-effects. Jan treats both women and their partners with acupuncture, as close as possible to egg pick-up and has found that acupuncture pre- and post-embryo transfer appears to support higher rates of implantation.
Introduce Herbs Following Egg Retrieval
Once eggs have been retrieved, Jan will then consider the addition of Chinese herbs to the treatment to support kidney yang and encourage higher levels of progesterone to maintain a thick, healthy endometrium that will sustain a growing foetus. Chinese herbs can also provide emotional support and help to keep the woman calm to prevent stress from impacting on her ability to achieve successful conception. At this stage in the cycle, Jan has found that many women are more than happy to add Chinese herbs to the mix, even if they are also using progesterone pessaries.
Case Study One by Jan McLay – Josie and Michael
Polycystic Ovarian Syndrome and Huntington’s Disease Gene – Male Factor
Josie and Michael were both aged 28 and veterans of four full IVF cycles, yet had not achieved successful conception. Josie had been diagnosed with Polycystic Ovarian Syndrome (PCOS) and Hashimoto’s disease, while Michael is a carrier of the Huntington’s disease (HD) gene.
Michael’s presenting symptoms included loss of libido, tiredness, lethargy and a general lack of zest. This combined with his pulse analysis indicated faltering kidney qi.
Josie presented with a long menstrual cycle of around 35 days. Her menstrual period was accompanied by lower back pain which was relieved with heat. Her menstrual flow was heavy and brownish-red in colour, and she had very light bleeding at the time of ovulation.
Josie was overweight but not obese and complained of feeling the cold quite severely. Tongue analysis revealed a pale tongue with teeth indentations and a red tip. Her pulse was submerged, a little soggy and sluggish. These signs suggested Josie was kidney and spleen yang deficient with accompanying damp, with some heart and liver qi stagnation. Jan had exactly four months to work with Josie before the next egg pick-up, and almost three of these months were focused on establishing a shorter and more regular cycle.
Michael was recommended the below comprehensive formula suggested by Jane Lyttleton: Shu di [Rehmannia cooked], shan yao [Dioscorea], shan zhu yu [Cornus], huang qi [Astragalus], dang shen [Codonopsis], bai zhu [Atractylodes, white], bai shao [White Peony], gou qi zi [Lycium fruit], tu si zi [Cuscuta], yin yang huo [Epimedium], mu dan pi [Moutan], nu zhen zi [Ligustrum], fu pen zi [Rubus chingii], he shou wu [Ho Shou Wu], suan zao ren [Zizyphus] - all 15 g plus lu jiao, ba ji tian [Morinda], suo yang [Cynomorium dongariorum], rou cong rong [Cistanche], dan shen [Salvia] - all 12 g.
When using Sun Ten/Classic TCM formulas a good alternative would be a combination of Liu Wei Di Huang Wan [Rehmannia Six Formula], You Gui Wan [Right Returning Formula] plus Ren Shen Yang Rong (Ying) Tang [Ginseng Nutritive Combination].
Josie was prescribed two main formulas for the different times of her cycle, which Jan uses with the majority of women she consults with fertility problems.
For the yin phase from day four through to ovulation Josie was prescribed Gui Shao Di Huang Tang, which is Liu Wei Di Huang Wan [Rehmannia Six Formula] plus dang gui [Angelica sinensis], he shou wu [Ho Shou Wu] and bai shao [White Peony]. In addition, Jan added the shen calming herbs he huan pi [Albizzia] and bai zi ren [Biota], plus small amounts of xu duan [Dipsacus], tu si zi [Cuscuta], sha ren [Cardamon], yi yi ren [Coix].
In Jan’s experience, IVF can cause major disruptions to the menstrual cycle, particularly in women suffering from PCOS where the cycle is already somewhat erratic. In this case, Josie took some time before she began ovulating. After ovulation, Josie was prescribed a variation of You Gui Wan [Right Returning Formula], to which Jan added xu duan [Dipsacus], yin yang huo [Epimedium], and bai zhu [Atractylodes, white].
To regulate her period, which was longer than usual, Josie took a combination of; fu ling [Hoelen], dang gui [Angelica sinensis], chuan xiong [Cnidium], bu gu zhi [Psoralea], tu si zi [Cuscuta], xiang fu [Cyperus], bai zhu [Atractylodes, white], shu di [Rehmannia cooked] and lu jiao. The formula Wen Jing Tang [Dang Gui & Evodia Combination] could also be useful.
Josie took variations on the above formulas up until her next IVF cycle. The IVF cycle produced good quality eggs and eight embryos, however embryo transfer again failed. Despite this, Josie felt very well throughout the entire process and two grade one embryos (minus the HD gene) were frozen.
Following this IVF cycle, Jan worked with Josie for several more months, rebalancing her cycle. This time, they found Josie’s cycle normalized to 32 days very easily. Four months later Josie underwent a frozen embryo transfer with no anxiety.
At the time of writing this article, Josie was 16 weeks pregnant, suffering morning sickness for nine weeks, probably as a result of spleen qi/yang deficiency and anxiety. Jan prescribed Shou Tai Wan [Foetus Longevity Pill], to be made up from equal amounts of tu si zi [Cuscuta], sang ji sheng [Loranthus], xu duan [Dipsacus], e jiao [Gelatin] for 12 weeks despite the sickness.
Case Study Two by Jan McLay – Charmaine
Since the age of 23, Charmaine had been trying to conceive in spite of a diagnosis of severe endometriosis and ‘mild’ PCOS. Charmaine’s periods began at 15, somewhat late and possibly an indication that all was not as it should be with her jing. Her first attempt with ART at the age of 25 was unsuccessful. Despite low oestrogen levels, Charmaine’s later IVF cycle was successful after a very high dosage of Puregon, an injection of FSH to stimulate ovulation. However, this pregnancy was far from smooth. Placenta previa was diagnosed at 18 weeks and Charmaine delivered a premature baby at 34 weeks.
After her first child, Charmaine attempted to fall pregnant again, with success. A frozen embryo transfer failed. Laparoscopy revealed rampant endometriosis, most of which was removed with surgery. After two failed IVF cycles, Charmaine responded to the Puregon and TCM on the third attempt, and at the time of writing this article, is 19 weeks pregnant with twins.
Kidney yin and possibly some jing xu (based on poor response to ART, later onset of menarche). Kidney yang xu (PCOS, endometriosis, feels the cold terribly, recurrent miscarriages) leading to blood stagnation (endometriosis and extremely painful periods with mild clotting, recurrent miscarriages).
Heart and liver qi stagnation.
Formulas: Variation of Gui Zhi Fu Ling Wan [Cinnamon & Hoelen Combination] to attempt to clear the blood stagnation plus the addition of warming herbs such as tu si zi [Cuscuta], xu duan [Dipsacus], gui zhi [Cinnamon Twigs]. In this instance Wen Jing Tang [Dang Gui & Evodia Combination] would be another formula to consider due to its warming properties which then aids in clearing blood stasis.
Due to the presence of large endometrial deposits, Jan added e zhu [Zedoaria], san leng [Rhizoma sparganii] at times, to address the severe pain and stimulate blood flow. At the same time, to guard against excessive bleeding, Jan prescribed pu huang [Pollen typhae] and wu ling zhi [Pteropus]. Keeping in mind the underlying liver qi stagnation, it is wise to include chai hu [Bupleurum], xiang fu [Cyperus], chuan lian zi [Melia] and perhaps he huan pi [Albizzia] and suan zao ren [Zizyphus] to address the heart qi.
Immediately following surgery to remove endometriosis, Jan aimed to build yin and blood, while keeping the endometriosis at bay.
From day four of the patient’s cycle through to ovulation, Charmaine took a variation of Gui Shao Di Huang Wan (Liu Wei Di Huang Wan [Rehmannia Six Formula] plus dang gui and bai shao) minus mu dan pi [Moutan], ze xie [Alisma] and including lu jiao [gelatinum cornu cervi], chuan xiong [Cnidium], tao ren [Persica], bai zhu [Atractylodes, white], chai hu [Bupleurum], tu si zi [Cuscuta] and suan zao ren [Zizyphus].
Ovulation did occur on day 14, after which, Charmaine was prescribed a variation of You Gui Wan [Right Returning Formula], replacing shu di [Rehmannia cooked], shan zhu yu [Cornus], shan yao [Dioscorea] and substituting fu ling [Hoelen], bai zhu [Atractylodes, white], xu duan [Dipsacus] and yin yang huo [Epimedium] in order to encourage kidney yang. During the frozen embryo transfer, Charmaine continued to take Gui Shao Di Huang Wan at the same time as oestrogen, although to no avail.
By the time of the successful cycle in which Charmaine conceived twins, she had continuously taken variations of the above two formulas, achieving nine eggs all of which were fertilised and three of which are now frozen. She was recommended Shou Tai Wan [Foetus Longevity Pill], to be made up from equal amounts of tu si zi [Cuscuta], sang ji sheng [Loranthus], xu duan [Dipsacus], e jiao [Gelatin] up until week 12.
The other important factor in this story was Charmaine’s change of attitude. When she simply decided to ‘dump’ her expectations, her impatience, her attempts to control the way in which she thought things should be done, interestingly, her periods became regular, the pain almost non-existent and the much hoped-for pregnancy was achieved.
Case Study Three by Jan McLay – Petra
Petra is 36, the mother of a two year old son who was conceived quickly and effortlessly. Shortly after the birth, Petra and her husband were anxious to conceive another child, with the intention of having at least two more children. By the time Petra came to see Jan, she and her partner had been trying to conceive for 20 months. The couple decided to attempt IVF after six months of trying to conceive unsuccessfully.
All investigations came back clear and the sperm analysis was regarded as ‘above average’. Three IUIs (intra uterine inseminations) were unsuccessful. Following this came three rounds of IVF, two medicated and one natural cycle. From these three cycles, seven blastocysts were created, four of which were transferred at various times and three of which remain frozen. There was no implantation at any stage.
Petra’s menstrual cycle was erratic, lasting anywhere between 21 to 30 days. She experienced heavy bleeding on the first day of her period, which was clot-free but accompanied by some low back pain. Mid-cycle mucus occurred sporadically, and pre-menstrually she was moody with tender breasts. Petra felt the cold very acutely.
The only major illness in Petra’s history had been glandular fever when she was 17. Her pulse was quite submerged and faint all round but on further depression there is a quite substantial strength to it. Her tongue was pale with red sides and tip.
Petra is a forceful but dynamic woman, who moves quickly, talks quickly and is impatient to achieve her goals. These qualities held her in good stead throughout the ART attempts as she did not allow herself to become consumed by sadness or negativity.
Kidney yin and yang were compromised with some blood deficiency, in addition to underlying liver and heart qi stagnation.
Petra was reminded that TCM might take a little longer than the biomedical approach. She was very reasonable and accepted Jan’s words of advice.
Gui Shao Di Huang Wan (Liu Wei Di Huang Wan [Rehmannia Six Formula]) plus dang gui [Angelica sinensis] and bai shao [White Peony]) plus dan shen [Salvia], chai hu [Bupleurum], bai zi ren [Biota] and he shou wu [Ho Shou Wu] from day four to ovulation.
After ovulation she switched to You Gui Wan [Right Returning Formula] plus xu duan [Dipsacus], bu gu zhi [Psoralea], ai ye [Mugwort Leaf].
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