TREATING INFERTILITY WITH CHINESE MEDICINEBy Cindy Micleu, L.Ac.

Throughout the menstrual cycle, changes in repro- Hunt, a research biologist at Washington Stateductive physiology are matched by energetic changes, University, has shown that repeated small exposures towith fluctuations of yin, yang, qi, and blood reflected in these chemicals found in everyday life specifically targetthe various phases of the cycle. Examining these the reproductive system and can cause severe geneticchanges in the follicular, ovulatory, luteal, and menstru- abnormalities in egg cells.'al phases, allows for a detailed view of a woman's repro- Statistics show one in eight people in the U.S. haveductive cycle. In the diagnosis and treatment of infertili- an infertility problem (Resolve: The National Infertilityty with Chinese medicine, the AOM perspective is Organization). This is a quickly growing patient popula-assessed with special regard for reproductive health, and tion. There has been a great deal of research on the usethe normal functioning of each specific stage of the men- of Chinese medicine in conjunction with ART (assistedstrual cycle is supported as needed. reproductive technology) with significantly positive out-

Treating the menstrual phases is also a strategy com- comes, which has led many fertility clinics to refermonly employed in cases of "unexplained infertility," a patients to Chinese medicine. Patients are often spendingdiagnosis frequently given when there are no specific a great deal of money on fertility technology, with expo-problems detected in a Western r;===============================;-, sure to high levels of chemical hor-medicine infertility evaluation. In CHONG RELEASE FORMULA mones. There is also the long-termthese cases, the ovarian follicles are S th I b J' X 7i 1501 emotional stress inherent in thepa 0 0 us I ue eng ... ,...... 10

developing normally on ultrasound Mimosa Tree Bark He Huan Pi 15% process. For many reasons, Chineseevaluation, hormone levels are in medicine practitioners are in a

1 d lati White Peony Bai Shao 12% . . . be i dnorma range, an ovu ation seems unique position to e Important anto be occurring properly. Pelvic Codonopsis Dang Shen 12% effective health care providers fororgans are structurally sound and White Atractylodes Bai Zhu 12% these patients.free of endometriosis and fibroid Angelica Sinensis Dang Gui 10%tumors, _ the end~eh'ial lining ._Red Peony Chi Shao 10% TREATING FEMALEbuilds adequately, and sperm Ligusticum Chuan Xiong 6% INFERTILITVTHROUGHparameters are within normal range. Persica Seed Tao Ren ; 5% THE MENSTRUALAdvanced age is often the assumed C rth H H 3°1 CYCLEa amus ong ua............... 10

problem in these infertility cases. L..::::::==============~==============:::::J Menstrual PhaseIn a Chinese medicine evaluation, more subtle cues Day 1 of the menstrual cycle is the first day of the

of imbalance may be detected, but not always. menstrual period. The actual definition of which day isSometimes infertility patients are seemingly robust and designated as "day 1" can vary from source to source.healthy, and often fairly young, yet they have significant Generally it is the first day of significant menstrualproblems conceiving. In fact, women in their 20's have bleeding, not just spotting. If the period begins in thethe fastest growing infertility rate of any age group, evening or during the night, from about 6pm-midnight,according to the National Center for Health Statistics. In "day 1" is considered to be the following day.Oriental medicine, the kidney and liver dominate repro- During menstruation, the endometrial lining of theduction, yet patients may have little or no symptoms of uterus is shed. A quick drop in progesterone usually pre-low back pain, nighttime heat, excessive dryness, or cedes the beginning of the period, and on day 1 both thefatigue, and their menstrual cycle and flow may be rela- estrogen and progesterone levels are relatively low.tively normal. They may have few complaints and no From a Chinese medicine point of view, with theclear diagnostic imbalance, though their liver and/or kid- loss of blood during menstruation, the ren and chongney pulses are weak. gradually empty, and by the time the menses is over the

In recent times, the term "reproductive health" has ren and chong, kidney yin, and liver blood are at theirbeen used to distinguish a person's general state of health lowest in the cycle. Problems during the menstrual peri-from that of their reproductive system. From a Western od are most commonly indicative of problems with qimedicine point of view, researchers are increasingly sus- and blood flow, while problems that occur or are worsepicious of the role that environmental toxins play on ris- towards the end of the menses are generally associateding infertility rates. Referred to as "endocrine disruptors" with blood deficiency.because they interfere with hormone function, some Treatment of infertility during the menstrual phasechemicals such as phthalates and bisphenol A (in many focuses on clearing any stagnation that may impede theplastics) have been implicated in rising rates of cancer, quality and movement of qi and blood in the followingmiscarriage and both male and female infertility. Patricia

2 INFERTILITY-----------------------------------------------------------------------------------------cycle. Clearing blood stasis facilitates the complete dis-charge of menstrual blood so that the new endometriallining can grow on a smooth, clean base. Some practi-tioners will use herbs to "flush" the uterine lining bloodduring menstruation, encouraging the complete dis-charge of the endometrium, even if there are no overtsymptoms of blood stasis. But in particular, if there aresigns of stasis such as clotting, cramping, or irregularbleeding, this may be a particularly useful strategy.

A base formula used during the menstrual phase isChong Release Formula (Jia Wei Tao Hong Si WuTang). Shu di was omitted from the traditional formuladue to its cloying nature, while herbs to support thespleen were added to reinforce the ability of the qi toexpel the blood effectively and to support the productionof blood after the loss during menstruation.

Secondarily, heat may be a problem during thisphase, as it easily causes damage to the yin, and canenter the blood prompting it to move recklessly at ovu-lation or menstruation. Heat can cause follicles to growtoo quickly, resulting in poor egg quality, and may causeearly ovulation and the shortening of the entire menstru-al cycle.

Heat in the follicular phase is commonly due to yindeficiency or stagnation of the heart and liver qi. Patientswith fertility problems frequently experience a great dealof stress when month after month they are unable to con-ceive. In these cases, heat from stagnation may disturbthe steady building of yin and blood, and is often seen inupward spikes in the basal body temperature.

Nourish Ren & Chong Formula (Jia Wei Gui ShaoDi Huang Wan) is a very effective formula for the follic-ular phase, nourishing both the yin and blood. The heart

r;==============================::::::;-] and liver may be addressed withNOURISH REN & CHONG FORMULA additions or modifications to the

formula.With the use of yin and blood

tonifying herbs, fertility signs oftenshow clear improvement. Long orshort follicular phases regulate, cer-vical mucus increases, menstrualblood quantity and quality improves,and basal body temperature chartsbecome more even. Correspondingly,western lab tests often showimprovement in follicle and endome-trial lining development.

Follicular PhaseThe follicular phase begins on

day 1 of the menstrual cycle whennew follicles, containing eggs,begin their growth. Clinically, wegenerally begin support of thisphase after the major menstrualblood flow is over, usually aroundday 4.

During the follicular phase,the hypothalamus and the pituitaryinteract, stimulating the pituitaryto release FSH (follicle stimulatinghormone), that in turn stimulatesthe maturation of the ovarian folli-cles. One of these follicles willgrow to become the largest, or dom-inant follicle, and will release its egg at ovulation.

The regeneration of the endometrium, or uterine lin-ing, begins about 2 days after the onset of menstruation,even though menstrual bleeding still continues. Thisprocess includes tissue repair of the uterus where the lin-ing has shed, as well as the development of estrogen andprogesterone receptors in the new tissue. Estrogen is thedominant hormone during this phase, and as the levelsgradually rise, proliferation of the endometrium and itsdense vascular network is stimulated. It also causes thecervix to produce cervical fluid.

From a Chinese medical perspective, follicle devel-opment is a yin process, dependent on yin, blood andessence. In the follicular phase, the Ren and Chong arefilling and the yin and blood are building as the folliclesgrow. Any tendency to yin and/or blood deficiencyshould be supported during this time in particular. Yinand blood deficiency affecting fertility may manifestwith poor follicular development, thin endometrial lin-ing, or decreased cervical mucus.

Chinese Yam Shan Yao 12%Angelica Sinensis Dang Gui 12%White Peony Sai Shao 12%Cured Rehmannia Root Shu Di Huang .. 10%Cornelian Cherry Shan Zhu Yu 9%Lycium Fruit Gou Qi Zi 9%Salvia Dan Shen 8%Gardenia Zhi Zi 8%Tree Peony Root Bark Mu Dan Pi 5%Poria Fu Ling 5%Asian Water Plantain Ze Xie .' .. 5%Tangerine Peel Chen Pi 5% Ovulatory Phase

When the main developing folliclebecomes large enough and estrogen reaches a certainlevel, ovulation will occur. Prior to ovulation, the hypo-thalamus and pituitary gland again playa major role asLH (luteinizing hormone) is released. This causes the"LH surge" which occurs about 24 hours prior to ovula-tion and is detected by an ovulation predictor kit.

In a normal, healthy ovulation, the basal body tem-perature chart will show a quick rise in temperature withthe LH surge, and temperatures will then stay relativelyhigh throughout the second half of the cycle. This isindicative of the quick change from yin dominance inthe follicular phase to yang dominance in the lutealphase. Ovulation itself depends on the yin and bloodbeing at their fullest, and the ensuing transformation offull yin to yang.

Yin at its fullest corresponds to the secretion of ovu-latory cervical mucus and follicle growth at its peak. Asit changes to yang, activity and movement are expressedas the dominant egg bursts forth from the follicle. Thisprocess of ovulation is dependent on the strength andfullness of yin, the ability to mobilize yang, and the

INFERTILITY

movement of qi and blood to facilitate transition. SIte on the ovary wall where the follicle released its egg.Specific treatment strategies in this stage are applied This gland secretes progesterone keeping the endometri-

when ovulation is early, delayed, or poor in general. This urn rich in hormones and nutrients and maintaining amay be seen in long cycles, in basal body temperature healthy environment for implantation. It also inhibits thecharts that are not biphasic (low temperatures in the fol- development of new eggs. Progesterone is the key hor-licular phase, higher temperatures in the luteal phase), or mone in the luteal phase of the cycle and is evident in thewhen ovulation predictor tests show no clear ovulation. higher basal body temperatures during this time.Some ovulatory problems such as The luteal phase is dominatedpolycystic ovary syndrome (PCOS) MOBILIZE ESSENCE FORMULA by qi and yang, but is also depend-and amenorrhea may be more com- ent on a good foundation ofyin and1· d d . if h b 1 Mimosa Tree Bark He Huan Pi 12% bl d In d c. . 1 .P icate an requIre speer IC er a 00. or er lor Imp antation to

treatment to address the particular Spatholobus Ji Xue Teng 11% occur, the uterine lining must beproblem. Angelica Sinensis Dang Gui 9% healthy and "receptive". The

The heart is also involved in Salvia Dan Shen 9% endometrium must be thick, moist,ovulation through the activity of the Ligustrum Nu Zhen Zi 9% and rich in blood and nutrients, abaa mai, the collateral connecting Cuscuta Tu Si Zi 9% very ym environment in which thethe heart to the uterus. The bao mai O· X D 901 fertilized egg burrows until it isipsacus u uan.................. 10

is one of the pathways by which the Wh't P B . Sh 801 completely buried by the end of theIe eony al ao . . . . . . . . . . . . . . .. 10

action of the heart qi and blood cycle.Poria Fu Ling 7%descend to the reproductive organs, Support of this phase generallyk . h . h d d f '1' Red Peony Chi Shao 7% bezi ith h b th t t ify theepmg t em nouns e an aCI 1- egms WI er s a om etating movement. The health of the Ligusticum Chuan Xiong 5% yang and qi, often including herbsheart and liver are key energies in Carthamus Hong Hua 5% to support the yin and/or blood asthe activity and vitality of trans i- well. In Chinese medicine gynecol-tions affecting the uterus. ogy, it is common practice to add yin tonic herbs when

Ovulation and the transition to the luteal phase of the treating the yang. Yin herbs are included to support thecycle can be inhibited_b_ stagnatioj; of gi, blood and/or foundation or root of the vangLand to protect the yinphlegm. Pain at ovulation or inability to ovulate in a from the warming nature of yang tonics.timely manner may be an indication of problems with In infertility treatment, ideally the yin and bloodthis transitional movement. r;:::==============================;l were already well nourished in

Mobilize Essence Formula (Fu YUAN SUPPORT FORMULA the follicular phase, and clearedRen Bu Yin Pian) is used for mid-cycle P I V' Yi J' T. 10°1 of stasis in the menstrual phase.o ygonum me e lao ,eng. . . . . . . . . 10

support. The formula invigorates the In the luteal phase it is appropri-bl d d . hil Chinese Yam Shan Yao 10% f

00 an removes stasis, w 1e pro- ate to continue this support 0ti h lth . c d ti d Cuscuta Tu Si Zi 10% d bl dmo mg a ea y ym roun a Ion an yin an 00.

the ability for yang to mobilize at ovu- Angelica Sinensis Dang Gui 9% Problems of the luteal phaselation. Herbs during this phase of the Oipsacus Xu Duan 9% may be seen in significant dropscycle are generally administered begin- White Peony Bai Shao 9% m basal body temperatures inning about 3 days before ovulation, or Codonopsis Dang Shen 8% the second half of the cycle, inwhen ovulation should ideally occur, White Atractylodes Bai Zhu 8% progesterone insufficiency,until 2 days after ovulation. Poria Fu Ling 8% problems with implantation,

Eucommia Bark Du Zhong 7% and the tendency to miscarriage.L· Fruit G Q' Z' 601 Although pre-menstrual stagna-ycunn nn ou I I.............. 10

tion is not itself an indicator ofBupleurum Root Chai Hu 6%an infertility problem, it may

well compound the difficulty, soaddressing the liver may be employed as a secondarytreatment principle.

Yuan Support Formula (Jia Wei Jian Gu Tang)supports the luteal phase well by tonifying and invigor-ating the yang and the spleen qi. The formula has beenmodified with herbs to support the yin and blood, tomove liver qi stagnation, and calm the spirit.

Luteal PhaseAfter the egg is released at ovulation,the sperm and egg travel to meet in thefallopian tubes, where a successfulsperm will penetrate and fertilize the egg. The egg must 'be fertilized in the fallopian tubes within about 12 hoursof ovulation, then it continues moving to the uterus toimplant in the endometrial lining. Implantation beginsabout 7 days after ovulation. The necessity of healthyyang to support movement and activity in this phase isclear.

After ovulation, the corpus luteum is formed at the

4 INFERTILITY-------------------------------------------------------------------------------

END OTEIHunt, PA, et. aI., The BisphenoJ A Experience: A Primer for the Analysis of Environmental Effects on Mammalian Reproduction, Biol Reprod,

May 20, 2009. .

CIND YMICLEU, L.Ac., is thefounder and director of the Jade Institute, located in Seattle, Washington. The Jade Instituteprovides educational programs for Oriental Medicine practitioners, emphasizing clinical relevance and a collaborativeapproach to health care. For more information you can visit the Jade Institute website at www.jadeinstitute.com

1) Menstrual PhaseChong Release Formula(Jia Wei Tao Hong Si Wu Tang)

• Yin and blood gradually decrease• Ren and chong become empty• Blood should be fully expelled and

stagnation in the uterus cleared

3) Ovulatory PhaseMobilize Essence Formula

(Fu Ren Bu Yin Pian)

• Follicles have been developing and largestprepares to release egg

• Growth of yin must be "exuberant" in orderto induce the yang movement of ovulation• Ovulation occurs with a quick change of

yin to yang• BBT temperatures rise quickly

2) Follicular PhaseNourish Ren & Chong Formula(Jia Wei Gui Shao Oi Huang Wan)

• Yin and blood gradually build to fill the renand chong

• Ovarian follicles are growing, estrogen levelsare rising

• Yin and blood are dominant• Basal body temperatures (BBT) stay

relatively low

4) Luteal PhaseYuan Support Formula(Jia Wei Jian Gu Tang)

• Progesterone becomes important• Qi and yang are dominant• Yin and blood remain important as material

basis of yang and qi• Fertilization and conception are dependent

on dynamic action of yang• BBT temperatures are ideally at least 4/10

degree higher than in follicular phase

Pre-Menses• Yang and qi should be strong and full, and move freely• As qi builds, stagnation may occur; heat easily generates

from stagnation• A strong foundation of yin is necessary to root yang• Yang heat may enter the blood• Typical formulas address heat and liver qi stagnation, such

as Free & Easy Wanderer Plus (Jia Wei Xiao Yao San)

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