INFERTILITY

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INFERTILITY

Infertility refers to the condition of a couple who have shared a common life for more than two years, during which time they have had a normal sexual life and have not adopted any birth control methods, but still have no pregnancy.

THE TIME period for diagnosing infertility was first recorded in the 11th Century BC in the book Yijing in which it says infertility is when `a married woman did not have a pregnancy after 3 years'. Since then, ie for the last 3000 years, the time limit/span for this diagnosis has been kept at three years. But this has recently been changed to a two year period on the basis of studies.

Infertility is divided into two kinds. One is primary infertility, the other is secondary infertility. Primary infertility refers to a person who has never had a pregnancy since having unprotected sexual relations. Secondary infertility refers to a person who has had a pregnancy but then becomes infertile.

In Chinese medicine primary infertility was called wu zi, quan bu chan, and jue ci in ancient books, and secondary infertility was called duan xu.

Pathogenic factors and Pathophysiology

Conception is a very complicated physiological process, and for normal conception the following three requirements are necessary:

There are normal germinal cells - normal sperm and ova.
Ovum and sperm can meet in the oviduct and become a fertilised ovum and then reach the uterine cavity.
There is a healthy endometrium and a fine internal environment of the uterus, so that the fertilised ovum can implant in it.
To meet these requirements a woman should (1) have a normal system of adrenal cortex, hypothalamus, pituitary and ovaries; (2) have a normal level of sexual hormones including gonadotrophin-releasing hormone, follicle stimulating hormone or luteinising hormone, prolactin, oestrogen and progestogen; (3) form and eject normal ova; (4) ovum and sperm can meet normally in the oviduct and become fertilised ovum; (5) have a normal oviduct so that the fertilised ovum can reach the cavity of the uterus; (6) have a healthy endometrium and fine internal environment of the uterus.

A man should (1) have a normal system of adrenal cortex, hypothalamus, pituitary, testes and epididymis; (2) have a normal level of sexual hormones including gonadotropic hormone, prolactin, testosterone; (3) be able to eject a normal volume of sperm; (4) have a normal spermatic duct and for the sperm to be able to be ejected at the post vault part of the vagina; (5) have normal blood circulation of all the genitals.

Therefore, if any part of the process is abnormal, infertility may appear and may be caused by both the man and woman. In diagnosis, a doctor should first find out whether the condition is due to the male or female partners.

In Chinese medicine, it is believed that a successful pregnancy is based on the fullness of kidney qi, mature tian gui, harmonious flow of the penetrating and conception vessels and timely compilation. In Su Wen: Shang Gu Tian Zhen Lun it says: `For a woman, at age 7, the kidney qi is full, at age 14 the tian gui comes, the conception vessel flows freely and the penetrating vessel is full, and menstruation comes regularly. Therefore a woman at this age can have a pregnancy. In Fu Ke Yu Chi, Qiu Ci it says: `For males, semen is taken as a dominant factor, while for females, blood is taken as a key aspect. If the young semen are abundant and the yin blood is flowing down regularly, and when the yin and yang are timely connected, there will form an embryo which will develop normally'.

In ancient works of Chinese medicine, the situations which may cause infertility of a man and a woman were named as five unmanlinesses and five unwomanlinesses. See Quang Ci, Ji Yao, Ze Pei Pian.

I. Five unwomanlinesses, are five signs of female sterility due to genital-organ deformities, including luo, wen, gu, jiao and mar.

Luo refers to spiral stria of the vulva or spiral vagina which makes coitus difficult.
Wen is also called wen yin. It refers to the situation of colpostenosis which makes coitus difficult.
Gu is the condition of imperforate hymen.
Jiao refers to hermaphroditism due to an exceedingly long clitoris.
Mai is the situation of amenorrhea due to menoxia which may cause primary infertility.
II. Five unmanlinesses, including tian, lou, jian, qie and bian.

Tian is congenital defects of the male external genitalia including shortness or absence of penis, absence of testis and undescended testis.
Lou is the condition of seminal emission which causes infertility.
Jian refers to resection of the penis or testes which usually was carried out in ancient China as a corporal punishment.
Qie means fear, in Chinese; it is male infertility due to a sexual disorder such as impotence, and so on.
Bian means change. It refers to male hermaphroditism.
In Shi Shi Mi Lu: Zi Ci Lun it says male infertility may be caused mainly by six diseases, and female infertility may be due to ten diseases. The six diseases of a man are blockage of semen, qi vacuity, scanty semen, excessive phlegm and effulgence of ministerial fire. The ten diseases of a woman include coldness of the womb, coldness of the stomach, depressed liver qi, excessive phlegm, vacuity of the kidney water, diseases of the governing vessel, vacuity of qi and blood, and inhibited transformative action of the urinary bladder qi, of which the most important are the following:

1. Vacuity of the kidney

This condition may be caused by a weak natural endowment which leads to vacuity of the kidney, or by sexual intemperance which damages blood and essence. When the kidney is vacuous, tian gui will not come and the blood of the penetrating and conception vessels is damaged too. The womb, therefore, is not well nourished and this makes it difficult to have a pregnancy. In Shen Ji Zong Lu it says, `female infertility is usually due to deficiency of the penetrating and conception vessels and vacuity cold of the kidney qi.'

2. Vacuity of blood

This condition is formed by poor constitution, vacuity of the spleen-stomach, or damage to the blood and fluids after a long-term disease. The vacuity of blood will cause deficiency of the sea of blood, thus the uterine vessels will fail to get good nourishment and this leads to infertility. In Ge Zhi Yu Lun it says: `A successful conception must be based on not only a normal discharge of yang - semen, but also on the absorbability of the yin blood. For a woman, the condition of infertility is frequently due to vacuity of blood and the weak ability for absorbing the young semen.'

3. Depressed liver

Long term emotional depression or over-strong desire to have a baby may cause depression of the liver which will further lead to a disorder of the liver's free coursing, disharmony of qi and blood, and disorder of the penetrating and conception vessels. This is one reason for infertility. So, in Fu Ke Yao Yao female infertility is due to menstrual irregularity, but the reason for menstrual irregularity is mainly related to the inner damage of the seven emotions.

4. Cold womb

The reasons for this condition include (a) the debility of the life-gate fire failing to warm the womb, (b) external or inner cold pathogens contracted during the menstrual period or after childbirth. When cold pathogens settle in the womb, the womb becomes too cold to absorb yang semen and fails to conceive. Just like the records in Ju Sheng Lu, `In the too cold and icy earth, there is no grass and trees. In the greatly cold water, there are no fishes. Hence if the womb is cold, for the same reason, it is difficult to have a pregnancy.'

5. Phlegm-damp

In this disease, phlegm-damp is due to (a) yang vacuity of the spleen and kidney which leads to failure of the movement and transformation of water. Water fails to be transported to all parts of the body but concentrates into phlegm and damp. (b) Indulgence in sweet and fatty foods which may also change into phlegm-damp. As a pathogenic factor, phlegm-damp can very easily block the uterus and cause infertility. So Zhu Dan Xi says: `The reason why a fat woman becomes infertile is that she is indulgent in sweet and fatty food or wine, which changes into phlegm-damp and blocks the womb.'

6. Blood stasis

This condition is usually formed by (a) inner emotional injury which further causes qi stagnation and blood stasis; (b) uncleaned blood after menstrual period or childbirth, which stagnates in the womb; (c) contracting a cold pathogen and then the blood is stagnated by the cold and becomes blood stasis.

When blood stasis appears, it will influence blood flow and cause the disharmony of the penetrating and conception vessels, and finally lead to infertility. In Yi Zong Jing Jian: Fu Ke Xin Fa it says: `The reason for female infertility is blood stasis blockage in the womb, while the new blood fails to absorb the semen.'

Factors related to female infertility
Factors affecting the production of the ova
(a) General diseases such as chronic wasting diseases, severe dystrophy, obesity, mental stress, etc.

(b) Disorders of the endocrine system, including hypothyroidism, hyperthyroidism and disorders of adrenocortical function.

(c) Imbalance of the function of the sexual glands, such as disorders of the system of the hypothalamus -- pituitary -- ovaries.

(d) Diseases of the ovary such as congenital aplasia or absence of the bilateral ovaries, oophoritis, ovarian tumour, etc. These diseases may result in infertility by influencing the production of ova.

2. Factors which influence the transport of ovum, sperm and fertilised ovum

(a) Deformity of the vagina, including congenital absence of vagina, transverse vaginal septum, imperforate hymen, etc. which all make normal sexual life difficult and cause infertility.

(b) Diseases of the uterine cervix.

(i) Myoma of cervix uteri, especially when the myoma blocks the opening of the uterine cervix. Sperm can not pass through.

(ii) Cervicitis. When there is inflammation in the cervix, the cervical mucus becomes thicker, and with adhering sperm, therefore results in infertility.

(c) Intrauterine adhesion.

This disease makes the sperm unable to pass through and reach the fallopian tube.

(d) Factors of the fallopian tubes.

(i) Diseases of the oviducts, such as congenital aplasia of oviduct, salpingitis obstruction of fallopian tube, tuberculosis of fallopian tube etc.

(ii) Tubal obstruction due to diseases of the pelvic cavity, such as compression of fallopian tubes by ovarian tumour, endometriosis or hysteromyoma. Inflammation of the pelvic cavity may cause adhesion of tubal fimbria and affect the intaking of the ova.

3. Factors which affect the nidation of the fertilised ovum

(a) Hyperactivity of the corpus luteum. In this condition, the secretion of progesterone is poor and the endometrium keeps a low secretory state, thus affecting the nidation and development of the fertilised ovum.

(b) Diseases of the womb. The diseases of the womb, like hypoplasia of the uterus, submucosal myoma of the uterus, hypoplasia of the endometrium, tuberculosis of the endometrium, etc. will make it difficult for the fertilised ovum to implant in it and result in infertility.

4. Immunological Factors

Of all cases of infertility, one fifth of them is due to an autoimmune response of the reproductive system, which is called immunological infertility.

(a) In women's infertility, autoimmunity is formed because the spermia and sperm, which act as antigens, are absorbed by the epithelia of the endometrium and vaginal mucosa. Thus antibodies for the spermia and sperm are produced by means of the immunological reaction system, and the antibodies will affect the combination of the sperm and ova, and even affect the nidation of the fertilised ovum.

(b) It was found that there was a kind of specific zona pellucida auto-antibody existing in the serum of women who suffered from infertility. This antibody may prevent the sperm from attaching and penetrating the ova.

2. Factors related to male infertility
1. Factors affecting the production of sperm
(a) Generalised diseases, especially chronic wasting diseases, obesity etc.

(b) Hormonal diseases, e.g. hypothyroidism, hyperadrenocorticism, etc. which may affect the function of the testes.

(c) Dysfunction of sexual glands and their regulatory system.

(d) Diseases of the testes, including hypoplasia of testis, tuberculosis of testis, injury of testis, orchitis, cryptorchidism, etc.

2. Factors affecting the quantity and vitality of the sperm In male infertility, reduction of quantity and vitality of the sperm is a common factor. Diseases such as varicocele, seminal vesiculitis, prostatitis, etc. may create this condition.
3. Factors affecting the transportation of the sperm
(a) Deformation of the external genital organs: Congenital absence of penis, too small a penis, too big a penis, hypospadias, hermaphroditism, injury of penis, inflammation of penis, hydrocele of tunica vaginalis, abscess of scrotum.

(b) Sexual disorder.

(c) Obstruction of spermatic duct.

(d) Immunological factors. Sperm agglutinin, a male auto-antibody, may cause sperm agglutination, greatly reduce the survival rate of sperm, and therefore is a common reason for male infertility. When the bloodtestis barrier is damaged, this antibody may exist in serum.

3. Factors related to both men and women
1. Lack of sexual knowledge.
2. Mental stress, especially the anxiety due to a long period of infertility.
4. Defect of the fertilised ovum
The sperm and ovum are all normal, but after combination, there appears disorder in the fertilised ovum during development.

Diagnosis

I. Clinical manifestation Primary infertility refers to a person who has never had a pregnancy during more than two years since beginning her/his sexual life without applying a birth control method during that period. Secondary infertility refers to a person who has an obstetric history, but now she/he has not had a baby for more than two years and did not adopt any birth control method during that time.

Women with infertility usually also have irregular menstruation, dysmenorrhea, disorder of vaginal discharge, pelvic inflammation, fatness etc, while men with infertility usually also have impotence, premature ejaculation, dribbling urinary incontinence etc.

II. Additional examination of the woman

General examination. In this examination a doctor should pay much attention to the development of the secondary sexual characteristics, eliminate TB, hypothyroidism, hyperadrenocorticism, pituitary disease, etc.
Gynaecological examination
Assessment of ovarian function
(a) Assessment of basal body temperature

(b) Cervical mucus examination

(c) Vagina cytology

(d) Endometrial biopsy

4. Tubal Patency test
5. Postcoital test
6. Combining test:
Test on cross combination of cervical mucus and sperm

III. Differential diagnosis

In the diagnosis of infertility, it is necessary to make a differential diagnosis to distinguish this condition from that of abortion within the first month of pregnancy. The difference can be found by testing the woman's basal body temperature, making an early pregnancy test or pathological examination.

Pattern identification and treatment determination

Having carefully gathered knowledge and information about the disease, the next important task during treatment is the identification of vacuity, xu, and repletion, shi, and cold and heat.

1. Identification of disease location

Though the basic disease location of infertility is in the kidney, the influence of the liver, spleen, qi and blood is very important too. The liver, governing the free coursing and storing of blood, plays an important role in regulating the penetrating vessel. The spleen-stomach is the root of posterior heaven and the source of engendering transformation of qi and blood. Normal menstruation and pregnancy are all based on the good nourishment of blood. In treatment, therefore, making a clear identification of the location of disease is an important aspect, especially to make out which of the kidney, liver, spleen, qi and blood has suffered severely.

2. Identification of vacuity and repletion

The difference of vacuity and repletion can be identified by the patient's age at menarche, constitution, nature of menstruation and vaginal discharge, dietary situation, urine and stool, general symptoms, tongue and pulse. For example, if the patient's menarche was late, her menstruation is usually delayed or at irregular intervals, with little, pale or dark, coloured blood, little vaginal discharge, the condition belongs to a vacuity pattern. But a repletion pattern usually has symptoms or signs such as dark purple menstrual discharge with small volume and lots of blood clots, accompanied with lower abdominal pain exacerbated by pressure, dark tongue with stasis speckles or macules and bowstring pulse.

3. Identification of cold and heat

A condition with symptoms of early periods with excessive thick and dark red menstrual flow, red tongue, and wiry slippery pulse belongs to a heat pattern. If the patient is having symptoms of late periods with thin, light-coloured and scanty inhibited menstrual flow, diarrhoea during the period, nocturia, pale tongue with thin and glossy tongue fur, this should be treated as a cold pattern.

4. Other

Generally, a patient who is fat can be identified as having a pattern of phlegm damp, but if the fat patient manifested with scanty vaginal discharge, she should be treated as spleen-kidney yang vacuity.In addition, some patients with infertility have no very obvious symptoms. In that situation, identification of patterns should be combined with identification of diseases.

It is recorded in many ancient works that infertility is usually caused by menstrual irregularity. For example, in Nei Zheng Zhi Cai, it is said that: `If there is a menstrual irregularity, there will be an infertility' In Nu Ke Zheng Zong it is also said that the most important basis of pregnancy is the strong and abundant sperm/essence for a man and regular menstrual cycle for a woman. Therefore, in treatment, a male patient should be treated by boosting essence and a female patient should be treated by regulating menstruation.

Clinical patterns

Here are the common clinical patterns of infertility:

1. Infertility due to kidney yin vacuity

Main symptoms: Being infertile for a long term after marriage, late menarche, scanty inhibited menstruation, or menstruation at irregular intervals, emaciation, dizziness, ringing in the ears like cicadas, aching lumbus and limp legs, vexing heat in the five hearts or tidal fever in the afternoon, red soft tongue with little fur, and weak fine pulse with rapid rate.

Analysis of signs of the pattern: Because the patient's congenital constitution is weak, the kidney is vacuous and the tian gui was not well filled, so the first menstrual flow came late. Since the kidney is vacuous, the essence and blood could not be well produced, and therefore manifested as scanty inhibited menstruation or menstruation at irregular intervals, the colour of the flow is pale. The blood did not nourish the body well, so manifested as emaciation. The vacuity of kidney yin will further affect the brain and marrow, hence bringing about dizziness, ringing in the ear, aching lumbus and limp legs. The vacuity of the yin will form inner heat so there appears vexing heat in the five hearts or tidal fever in the afternoon. The signs of red soft tongue with little fur, weak fine and rapid pulse are features of the vacuity of the kidney yin and the inner heat. Since the yin and blood are too weak to absorb the semen, the disorder of infertility is brought about.

Principle of treatment: To enrich yin and supplement the blood, and regulate menstruation.

Prescription and herbs: Yang Jing Zhong Yu Tang, from `Fu Ging Zhu's Women's Medicine' adding gou qi zi, tu si zi, and nu zhen zi. Radix Angelicae Sinensis dang gui

12g Radix Paeoniae Lactiflorae bai shao

10g Radix Rehmanniae Glutinosae shu di

15g Semen Cuscutae tu si zi

15g Fructus Corni Officinalis shan yu rou

10g Fructus Lycii Chinensis gou qi zi

15g Fructus Ligustri Lucidi nu zhen zi

15g

Interpretation of the prescription: In the prescription, shu di, shan yu rou and tu si zi are used to enrich the kidney essence; dang gui, bai shao and gou qi zi are used to enrich yin and supplement blood, nu zhen zi to enrich yin and replenish essence, and the whole prescription is made for enriching ying, supplementing blood, replenishing essence and regulating the menstruation. Therefore, infertility with this pattern will be treated.In the above pattern, if the vacuity heat is more obvious, add han lian cao Herba Ecliptae Prostratae 15g and di gu pi Cortex Lycii Chinensis Radicis 10g to enrich yin and clear the vacuity heat.

If the inner heat enters the blood chamber and gives rise to irregularity of menstruation, or incessant menstrual flow, or ulceration of the mouth appears during menstruation, the prescription of Qing Qu Zi Shen Tang `from `Fu Ging Zhu's Women's Medicine' should be selected adding zhi mu, gui ban and chuan niu xi. Cortex Lycii Chinensis Radicis di gu pi

12g Cortex Moutan Radicis dan pi

12g Radix Adenophorae seu Glehniae sha shen

12g Tuber Ophiopogonis Japonici mai dong

15g Radix Scrophulariae Ningpoensis xuan shen

12g Fructus Schisandrae Chinensis wu wei zi

10g Rhizoma Atractylodis Macrocephalae bai zhu

10g Herba Dendrobii shi hu

10g Radix Anemarrhenae Asphodeloidis zhi mu

10g Plastrum Testudinis gui ban

12g Radix Cyathulae chuan niu xi

10g

In this formula, di gu pi, dan pi and zhi mu are used to enrich yin and clear the heat; sha shen, mai dong and xuan shen are used to enrich yin and engender fluid, gui ban to enrich yin and replenish essence; wu wei zi to constrain yin for its sour flavour; bai zhu and shi hu to fortify the spleen for supplementing the source of the water. Niu xi can conduct the fire down and return it to its source. The whole prescription can clear the heat by enriching the yin. This method is called `Invigorating the governor of water to restrain the brilliance of yang'. Now that the vacuity heat has been cleared, the blood chamber will become clean and the infertility of this pattern will be treated.

2. Infertility due to kidney yang vacuity

Main symptoms: Being infertile for a long period, delayed menstruation with little volume and pale thin flow, or the flow is dark and watery, aching lumbus and limp legs, nocturia, lack of warmth in the lumbus and the lower limbs, sombre facial complexion or with yellow-brown macules, thin soft tongue fur, and deep fine pulse especially weak at the chi positions.

Analysis of the signs and symptoms: Because the kidney yang was vacuous, the penetrating and conception vessels were not nourished and warmed, and the blood chamber was insufficient, so there appeared delayed menstruation with little volume and pale thin flow. The kidney yang failed to warm and, therefore, the patient manifested with aching lumbus and limp legs, lack of warmth in the lumbus and lower limbs. The kidney yang failed to conduct normal transformative action, so there was resulting nocturia. The sombre facial complexion or yellow-brown macules are signs of the failure to warm the kidney yang and so are the signs of soft pale thin tongue fur, deep fine pulse especially weak at the chi positions. Because the kidney yang was insufficient, the penetrating and conception vessels were irregular, hence giving rise to infertility.

Principle of treatment: to warm the kidney yang, replenish the essence and regulate menstruation.

Prescription and herbs: Liu Ling Zhu `Jing Jue Quan Shu' adding zi he che and ba ji tian. Radix Ginseng ren shen

10g Radix Codonopsitis Pilosulae (or dang shen 15g) Rhizome Atractylodes Macrocephalae bai zhu

12g Sclerotium Proiae Cocos fu ling

15g Prepared Radix Glycyrrhizae Uralensis zhi gan cao

10g Radix Angelicae Sinensis dang gui

15g Radix Ligustici Wallichii chuan xiong

10g Radix Paeoniae Lactiflorae bai shao

10g Radix Rehmanniae Glutinosae Conquitae shu di

15g Semen Cuscutae Chinensis tu si zi

15g Cortex Eucommiae Ulmoidis du zhong

10g Cornu Cervi Degelatinatium lu jiao shuang

10g Fructus Zanthoxyli Bungeani chuan jiao

10g Placenta Hominis zi he che

10g No latin name bai ji tian

10g

Interpretation of the prescription: In this prescription, zi he che, tu si zi, du zhong, ba ji tian and lu jiao shuang are selected for warming the kidney and restoring yang, supplementing yin and replenishing essence, thus the kidney and the liver are supplemented together. Shu di, dang gui, bai shao, chuan xiong for nourishing blood in order to engender the essence; ten shen, bai zhu, fu ling and zhi gan cao are used to supplement qi, letting the posterior heaven qi nourish the congenital essence; chuan jiao is used to warm the kidney and invigorate yang, and in addition, chuan jiao can enter the governing vessel, for it is reported in a classic work that infertility of a woman is a disease of the governing vessel. So the prescription is made mainly for warming the kidney yang, added with the posterior heaven qi, and assisted by the yang channel conducting herbs, so that the disease could be eliminated.

3. Infertility due to blood vacuity

Main symptoms: Infertility for a long time, delayed menstruation, with little volume and pale colour, emaciation, dizziness, withered yellow facial complexion, dry skin, palpitations, reduced sleep, pale tongue with thin or no fur, and weak fine pulse.

Analysis of the signs and symptoms: Because the blood is insufficient, the penetrating and conception vessels are vacuous too, therefore the patient manifests with delayed menstruation with a small amount of pale flow. The vacuous blood fails to nourish the upper orifices, causing dizziness; the blood fails to nourish the external parts, manifesting as emaciation, withered yellow facial complexion and dry skin. The blood fails to nourish the heart so a patient complains of palpitations and reduced sleep. Pale tongue with thick or no fur, weak fine pulse are all the features of the pattern of blood vacuity.

Principle of treatment: nourishing blood, enriching the kidney and regulating menstruation.

Prescription and herbs: Yang Jing Zhong Yu Tang `Fu Ging Zhu's Women's Medicine', adding zi he che and tu si zi. Radix Rehmanniae Glutinosae shu di

15g Radix Angelicae Sinensis dang gui

12g Radix Paeoniae Lactiflorae bai shao

10g Fructus Corni Officinalis shan yu rou

10g Placenta Hominis zi he che

10g Semen Cuscutae Chinensis tu si zi

15g

This prescription is similar to the prescription for infertility due to yin vacuity, but use zi he che to take the place of Fructus Lycii gou qi zi and Fructus Ligustri Lucidi nu zhen zi, for zi he che can greatly supplement blood and essence.

If the patient also complains of weak food intake, mix 15g Fructus Amomi sha ren with Radix Rehmanniae Glutinosae shu di and then use it, and add Rhizoma Acori Graminei shi chang pu 10g.

If the blood vacuity formed is due to the vacuity of the spleen-stomach, use the prescription Ba Zhen Tang for dual supplementation of qi and blood. Radix Rehmanniae Glutinosae shu di

15g Radix Paeoniae Lactiflorae bai shao

10g Radix Angelicae Sinensis dang gui

15g Radix Ligustici Chuanxiong chuan xiong

10g Radix Codonopsitis Pilosulae dang sheng

15g Rhizoma Atractylodis Macrocephalae bai zhu

12g Sclerotium Poriae Cocos fu ling

15g Prepared Radix Glycyrrhizae Uralensis zhi gan cao

10g

Dual vacuity of qi and blood with cold should be treated with the modified Ren Shen Yang Rong Tang `He Ji Ju Fang': Radix Paeoniae Lactiflorae bai shao

10g Radix Angelicae Sinensis dang gui

15g Pericarpium Citri Reticulatae chen pi

10g Radix Astragali huang qi

12g Cortex Cinnamomi Cassiae rou gui

10g Radix Ginseng ren shen

10g Rhizoma Atractylodis Macrocephalae bai zhu

12g Radix Glycyrrhizae Uralensis gan cao

6g Radix Rehmanniae Glutinosae shu di

15g Fructus Schisandrae Chinensis wu wei zi

10g Sclerotium Poriae Cocos fu ling

15g Radix Polygalae Tenuifoliae yuan zhi

6g
4. Infertility due to depressed liver
Main signs and symptoms: Infertility for a long period, menstruation at irregular intervals, with irregular volume, dark red menstrual flow. Usually mixed with blood clots, vexation, irascibility, painful distension in the chest and lateral costal region, normal or dark tongue, with thin white fur, and wiry pulse.

Analysis of signs and symptoms: Because the depressed liver fails to conduct normal free coursing, and the normal movement of qi is obstructed, it therefore gives rise to disharmonization of qi and blood, irregularity of penetrating and conception vessels and manifests as infertility, menstruation at irregular intervals with more or less volume of dark coloured flow. In this condition, the patient usually has a great desire to have a child, being restless with anxiety, which may even cause the depression of the liver. So, qi and blood cannot move smoothly, and manifest as menstrual flow mixed with blood clots, painful distension in the chest and lateral costal region, dark tongue and wiry pulse.

Treatment: (1) Taking the psychological therapy as the main method. (2) To course the liver and resolve depression Prescription and herbs: Xiao Yao San He Ji Ju Fang' Radix Bupleuri chai hu

10g Radix Paeoniae Lactiflorae bai shao

10g Radix Angelicae Sinensis dang gui

12g Rhizoma Atractylodis Macrocephalae bai zhu

10g Sclerotium Poriae Cocos fu ling

5g Radix Glycyrrhizae Uralensis gan cao

10g No latin name wei jiang

10g Herba Menthae Haplocalycis bo he

10g

Interpretation of the formula: Because the liver is yin in substance, dang gui and bai shao are selected to nourish the blood and soothe the liver, chai hu to course the liver and resolve depression. Bo he is used to assist the action of coursing the liver and regulating qi. Bai zhu, fu ling, gan cao and wei jiang are used to bank up earth and depress wood. Therefore, the formula may course the liver and resolve depression, nourish blood and soothe the liver so as to harmonise the penetrating and conception vessels.

If the patient also has signs of blood vacuity, the vinegar prepared chai hu is more suitable than the normal one. If heat appears after a long term of qi depression, wei jiang should be taken out.

5. Infertility due to cold uterus

Main signs and symptoms: Infertility for a long period, delayed menstruation with small volume, dark colour and lots of blood clots. Cold pain or gripping pain in the lower abdomen during menstrual periods and the pain can be reduced by pressure. Profuse thin white vaginal discharge, pale tongue with white thin fur, and weak deep fine pulse.

Analysis of the signs and symptoms: Because of the debility of the life-gate fire, the uterus fails to be warmed, the production of qi and blood becomes slow, so menstruation comes late, and with small volume. Cold may cause blood congealing, so that is why the menstrual flow is dark with lots of blood clots. Cold pain or gripping pain is caused by the contraction and tension due to cold. The weak life-gate fire can not transform qi and liquids well and moves them to all parts of the body but changes into damp turbidity and goes downwards, manifesting as profuse thin white vaginal discharge. Pale tongue with white thin fur, and weak deep fine pulse are also signs of yang vacuity. Just as trees cannot be planted in winter, a foetus cannot grow in a cold uterus.

Principle of treatment: warming yang and the uterus, regulating menstruation.

Prescription and herbs: Luan Gong Jian `Xian Dai Zhong Xi Yi Fu Ke Da Quan' Prepared Aconiti Carmichaeli shu fu zi

10g Cortex Cinnamomi Cassiae rou gui

10g Semen Cuscutae Chinensis tu si zi

15g Radix Codonopsitis Pilosulae dang shen

15g No latin name chao du zhong

12g Radix Dioscoreae Oppositae shan yao

15g Radix Rehmanniae Glutinosae shu di

15g Fluoritum zi shi ying

20g Rhizoma Atractylodis Macrocephlae bai zhu

15g Rhizoma Phragmitis Communis wei jiang

10g

In this formula, fu zi and rou gui are used to supplement the fire of the life-gate, zi shi yin and wei jiang to warm the uterus and remove cold; dang shen and bai zhu to supplement qi and support yang; tu si zi, du zhong, shan yao and shu di to supplement the kidney and replenish essence.

If the patient's lower abdominal cold pain resists pressure and is accompanied by thin stool, cold body and limbs, sombre white facial complexion, and deep tight pulse, the pattern must belong to the excessive cold pattern, and the following should be added: Fructus Evodiae Rutaecarpae wu zhu yu 10g, Folium Artemisiae ai ye 6g, Herba Asari cum Radice xi xin 3g for warming the channels and dispelling cold. Add Radix Salviae Milfiorrhizae dan shen 15g, Fructus Crataegi shah zha 15g for quickening blood and relieving pain.

6. Infertility due to phlegm-damp

Main signs and symptoms: Infertility, fatness, irregular menstruation with light-coloured flow, or menstrual blockage, profuse white thick vaginal discharge, dizziness, heavy-headedness. Blank taste and sickly feeling in the mouth. Slimy white tongue fur and slippery pulse.

Analysis of the signs and symptoms: Because the phlegm-damp affects the qi dynamism and blocks the uterus, making pregnancy difficult, in this way the essence of grain and water does not produce qi and blood but changes into phlegm and damp, which causes irregular menstruation, light-coloured menstrual discharge or menstrual blockage, and profuse white thick vaginal discharge. The phlegm-damp harasses the upper body, manifesting as dizziness and heavy-headedness.The blank taste and sickly feeling in the mouth are due to the phlegm-damp affecting the spleen. Slimy white tongue fur and slippery pulse are signs of phlegm-damp too.

Principle of treatment: To dry damp and transform phlegm, rectify qi and regulate menstruation.

Prescription and herbs: Cang Fu Dao Tan Wan `Ye Tian Shi Nu Ke Zheng Zhi Mi Fang' Sclerotium Poriae Cocos fu ling

15g Rhizoma Pinelliae Ternatae ban xia

10g Pericarpium Citri Reticulatae chen pi

10g Radix Glycyrrhizae Uralensis gan cao

10g Rhizoma Atractylodis cang zhu

12g Rhizoma Cyperi Rotundi xiang fu

10g Rhizoma Arisaematis nan xing

10g No latin name zhi qiao

15g Rhizoma Zingiberis Officinalis Recens sheng jiang

3 pieces Massa Fermentata shen qu

15g

In this prescription, fu ling, ban xia, chen pi and gan cao are used to dry damp and transform phlegm, fortify the spleen and harmonise the stomach, cang zhu to dry damp and fortify the spleen, nan xing to sweep phlegm and dry damp, xiang fu and zhi qiao to rectify qi, Cortex Zingiberis Officinalis Recens sheng jiang and Massa Fermentata shen qu to warm the stomach and disperse food. Therefore the herbs clear up the uterus and promote pregnancy. If there is inhibited menstrual flow or menstrual blockage, add Radix Angelicae Sinensis dang gui 15g and Radix Ligustici Wallichii chuan xiong 10g to quicken the blood and dispel blood stasis.

If the blocked phlegm-damp further results in heat, and with yellow thick vaginal discharge, yellow slimy tongue fur and rapid pulse, it is necessary to add Radix Scutellariae Baicalensis huang qin 10g and Cortex Phellodendri huang bai 10g to remove heat and dry damp.

If the patient complains of glomus (stuffiness) and oppression in the chest and renter, or nausea and retching, add Caulis Bambusai in Taeniis, zhu ru 10g and Cortex Magnoliae Officinalis, hou po 10g to strengthen the power of transforming phlegm.

7. Infertility due to blood stasis

Main signs and symptoms: Being infertile for a long time, or having had a history of pregnancy but now having been infertile for more than two years; inhibited menstruation, dark red menstrual discharge with lots of blood clots. Pain in the lower abdomen resisting pressure, and the pain being severe before being discharged, but becomes better after discharge; distension and fullness in the chest and lateral costal region; vexation, irascibility, lack of warmth in the lower abdomen and limbs; dark purple tongue with stasis speckles or macules, and wiry choppy pulse.

Analysis of the signs and symptoms: Blood stasis may be caused by both qi stagnation and congealing cold. The distension and fullness in the chest and lateral costal region, vexation and irascibility are all manifestations of qi stagnation, while the symptoms of lack of warmth in the lower abdomen and limbs are signs of congealing cold. For whatever reasons it is caused, the blood stasis obstructs the movement of blood and manifests as inhibited menstrual flow with dark red colour and lots of blood clots. Dark purple tongue with stasis speckles or macules and wiry choppy pulse are also signs of blood stasis pattern. Because the penetrating and conception vessels are blocked by the blood stasis, this therefore results in infertility.

Principle of treatment: rectifying qi and quickening blood, removing stasis and regulating menstruation.

Prescription and Herbs: Xue Fu Zhu Yu Tang `Yi Lin Gai Cuo' Radix Angelicae Sinensis dang gui

15g Radix Rehmanniae Glutinosae shu di

15g Semen Persicae tao ren

10g Flos Carthami Tinctorii hong hua

12g No latin name zhi qiao

15g Radix Paeoniae Rubra chi shao

12g Radix Bupleuri chai hu

10g Radix Glycyrrhizae Uralensis gan cao

10g Radix Platycodi Grandiflori jie geng

10g Radix Ligustici Chuanxiong chuan xiong

10g Radix Achyranthis Bidentatae niu xi

15g

In this prescription, chai hu and zhi qiao are used to rectify qi and course the liver, the decoction of Tao Hong Si Wu Tang is used to nourish and quicken the blood, jie geng to rectify qi, niu xi to conduct the blood downwards, and shao yao and gan cao to relax tension and relieve pain. If the pain is severe, add Hirudo Seu Whitmaniae, shui zhi 10g to assist the power of blood quickening.

If the blood stasis is obviously caused by cold, it is necessary to warm the channel and dispel cold, remove stasis and stop pain, selecting: Shao Fu Zhu Yu Tang `Yi Lin Gai Cuo' Fructus Foenculi Vulgaris xiao hui xiong

10g Rhizoma Zingiberis Officinalis gan jiang

10g Rhizoma Corydalis Yanhusuo yan hu suo

10g Myrrha mo yao

10g Radix Angelicae Sinensis dang gui

15g Radix Ligustici Chuanxiong chuan xiong

10g Cortex Cinnamomi Cassiae rou gui

10g Radix Paeoniae Rubrae chi shao

15g Pollen Typhae pu huang

15g Excrementum Trogopteroi seu Pteromi wu ling zhi

10g

Xiao hu xiong, gan jiang and rou gui in the prescription are used to warm the channel and dispel cold, for blood will move after warming. Pu huang, wu ling zhi, yan hu suo and mo yao are used to rectify qi and quicken blood in order to remove stasis and relieve pain. Dang gui, chuan xiong and chi shao are used to nourish and quicken blood.

Clinical observations

Stages of Treatment

In the recent year, a sequential treatment for infertility with Chinese herbal medicine has been applied in the clinic.

According to the characteristics of the different period during the menstrual cycle, the treatment is divided into three stages. During the menstrual period, the physiological characteristic of the uterus is just to discharge, not store. In treatment, therefore, from the first day of the menstrual flow the principle of nourishing and quickening blood should be used.

After the menstrual period, the uterus becomes vacuous and is empty. In this period, the principle is to nourish the blood and replenish the essence in order to supplement the liver and kidney at the same time. Herbs for warming kidney yang and quickening the blood are useful during this period. It was proved in clinical study that warming the kidney yang may promote ovulation. The third stage is after ovulation, in light of the rule `To supplement the spleen and stomach so as to support the source of blood, to supplement the kidney in order to quieten the blood chamber'. (Jing Yue Quan Shu, Fu Ren Gui), treatment for supplementing the spleen and kidney is applied.

1. Nourishing and quickening blood. This method should be used from the first day when menstrual flow begins. The prescription comes from Tao Hong Si Wu Tang, adding dang shen, dan shen, yi mu cao and chuan niu xi.

Radix Rehmanniae

Glutinosae Conquitae

shu di

15g

Radix Angelicae

dang gui

15g

Radix Paeoniae Rubrae

chi shao

12g

Radix Ligustici Chuanxiong

chuan xiong

10g

Semen Persicae

tao ren

10g

Flos Carthimi Tinctorii

hong hua

10g

Radix Codonopsitis Pilosulae

dang shen

15g

Radix Salviae Milfiorrhizae

dan shen

15g

Herba Leonuri Heterophylli

yi mu cao

15g

Radix Cyathulae Officinalis

chuan niu xi

12g
3 Bags, I Bag per Day
If there are obvious symptoms of qi stagnation and blood stasis, add Tuber Curcumae yu jin 10g and (no Latin name) zhi qiao 15g. If there are signs of cold, the prescription of Da Bao Wen Jing Tang should be used.

2. (a) Enriching the liver and kidney, nourishing blood and regulating menstruation.

The prescription of Yu Bao Yin (from the author's experience)

Semen Cuscutae Chinensis

tu si zi

15g

Fructus Ligustri Lucidi

nu zhen zi

15g

Fructus Lycii

gou qi zi

15g

Rhizoma Polygonati

huang jing

15g

Radix Angelicae Sinensis

dang gui

15g

Placenta Hominis

zi he che

15

Radix Codonopsitis Pilosulae

dang shen

12g

Herba Epimedii

xian ling pi

10g

Herba Cynomorii Songarici

suo yang

10g
5 - 10 Bags, 1 Bag per Day
This prescription may promote the development of the follicle.

(b) Nourishing the liver and kidney and assisting with warming yang and quickening blood, using Cu Pai Luan Tang (from the author's experience).

Semen Cuscutae Chinensis

tu si zi

15g

Fructus Lycii

gou qi zi

15g

Radix Angelicae Sinensis

dang gui

15g

Cortex Cinnamomi Cassiae

rou gui

10g

Radix Salviae Milfiorrhizae

dan shen

15g

Rhizoma Radix Notopteryqgii

qiang huo

10g

Placenta Hominis

zi he che

10g

Radix Polygoni Multiflori

he shou wu

10g

Radix Codonopsitis Pilosulae

dang shen

12g

Herba Epimedii

xian ling pi

10g

Rhizoma Polygonati

huang jing

15g
3 -5 Bags, 1 Bag per Day
3. Supplementing the spleen and kidney.
The spleen and kidney are the source of blood, therefore they are the basis for quietening and nourishing the foetus. In this period, the prescription of Liang Gu Tang is used (from the author's experience).

Semen Cuscutae Chinensis

tu si zi

15g

Radix Morindae Officinalis

ba ji tian

10g

Fructus Lycii

gou qi zi

15g

Radix Codonopsitis Pilosulae

dang shen

15g

Radix Dioscoreae Oppositae

shan yao

15g

Polygoni Multiflori

he shou wu

12g

Cortex Eucommiae Ulmoidis

du zhong

12g

Herba Cistanches

rou cong rong

12g

Herba Epimedii

xian ling pi

10g

Herba Cynomorii Sangarici

suo yang

10g

Radix Angelicae Sinensis

dang gui

12g
7 - 12 Bags, 1 Bag per Day
If the patient complains of thin stool, add prepared Rhizoma Atractylodis Macrocephalae bai zhu 25g, Sclerotium Poriae Cocos fu ling 15g. It was reported that this prescription may improve the function of the corpus luteum.

Sequential treatment of infertility caused by stromal endometriosis of uterus

There are about 10% of cases of infertility from stromal endometriosis of the uterus. 20 - 60% of cases of stromal endometriosis may result in infertility. In the treatment of infertility of this type, the following sequential therapy with Chinese herbal medicine should be applied: 1) To quicken the blood and remove blood stasis; 2) To supplement the liver and kidney, and warm the yang and quicken the blood; 3) To supplement the kidney and regulate the liver.

(1) Method of quickening blood and removing blood stasis.

The patient should take the medicine from 1 to 2 days before the menstrual onset until the end of that period, selecting the prescription of Zhu Yu Tiao Jing Tao (from the author's experience).

Ramulus Cinnamomi Cassiae

gui zhi

10g

Rhizoma Sparganii

san leng

12g

Rhizoma Curcumae Zedoariae

e zhu

12g

Radix Paeoniae Rubra

chi shao

15g

Cortex Mountan Radicis

dan pi

15g

No latin name

shu zhi

10g

Radix Angelicae Sinensis

dang gui

15g

Myrrha

mo yao

10g

Radix Salviae Miltiorrhizae

dan shen

15g

This prescription may obviously reduce menorrhea for patients who have hypermenorrhea.

(2) Method of supplementing the kidney and liver, warming yang and quickening blood.

The medicine should be taken from 2-3 days before the ovulatory period, selecting Yu Bao Yin (from the author's experience).

Semen Cuscutae Chinensis

tu si zi

15g

Radix Rehmanniae

Glutinosae Conquitae

shu di

15g

Fructus Lycii Chinensis

gou qi zi

15g

Radix Angelicae Sinensis

dang gui

12g

Cortex Cinnamomi Cassiae

rou gui

10g

Radix Salviae Miltiorrhizae

dan shen

15g

Rhizoma et Radix

Notopterygii qiang huo

10g

No latin name

zhi qiao

15g

Fructus Rubi

fu pen zi

12g

Herba Cynomorii Sorgarici

suo yang

10g

Flos Carthami Tinctorii

hong hua

10g

Radix Achyranthis Bidentatae

huai niu xi

15g
3 - 5 Bags, 1 Bag per Day
If there is a dysfunction of ovulation, Radix Salviae Milfiorrhizae dan shen should be used as doubled weight. If there are signs of cold, add Radix Lateralis Aconiti Carmichaeli Preparata fu zi 10g.

(3) Method of supplementing the kidney and liver.

The medicine should be adopted during the luteal phase and using Yi Shen Tiao Gan Tang (from the author's experience).

Radix Bupleuri

chai hu

10g

Radix Angelicae Sinensis

dang gui

15g

Radix Paeoniae Lactiflorae

bai shao

10g

Semen Cuscutae Chinensis

tu si zi

15g

Hominis Placenta

zi he che

10g

Fructus Rubi Chingii

fu pen zi

12g

Radix Polygori Multiflori

he shou wu

15g

No latin name

chao du zhong

12g

Radix Dipsaci Asperi

chuan duan

20g

Herba Epimedii

xian ling pi

10g

Radix Codonopsitis Pilosulae

dang shen

15g

If the patient complains of thin stool during menstrual period, add prepared Rhizoma Atractylodis Macrocephalae bai zhu 15-25g.

Treatment of the infertility caused by Cervicitis

The main clinical manifestations include thick cervical mucus, purulent cervical mucus, with massive leucocyte. In this condition, the prescription of Hong Teng Jie Du Tang should be taken (from the author's experience).

Flos Lonicerae Japonicae

yin hua

15g

Fructus Forsythiae Suspensae

lian qiao

15g

Caulis Sargentodoxae

Cuneatae hong teng

15g

Cortex Phellodendri

huang bai

10g

Radix Scullariae Baicalensis

huang qin

10g

Semen Coicis Lachryma-jobi

yi ren

15g

Cortex Poriae Cocos

fu ling

15g

No latin name

chao qian shi

12g

Radix Glycyrrhizae Uralensis

sheng gan cao

10g

Semen Plantaginis

che qian zi

10g

External medicine: Wai Yan Qing Jie San (from the author's experience).

No latin name

ying hua

No latin name

huang hai

Fructus Forsythiae Suspensae

lian qiao

No latin name

bai pu

Radix Soporae Flavescentis

ku shen

Radix Glycyrrhizae Uralensis

sheng an cao

Each of same weight of the above herbs are mixed together and then made into a thin powder. Put 1g of the powder into the neck of the uterus once a day.

British Acupuncture Council (BAcC).

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By Zhiqiang

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