Many patients 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. 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.

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 Menstrual Cycle in TCM Terms

Menstrual Phase: Day 1-Day 4

The treatment goal during the menstrual phase is to gently move and tonify qi and blood. If an obstruction to the flow of blood is present a Chinese herbal formula might be recommended.

The “Yin Phase” (follicular phase), day 5 to 2 days before ovulation

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 ovulation phase, 1-2 days before ovulation – The Switch from Yin (follicular) to Yang (luteal) 

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” (luteal phase), from ovulation until the confirmation of pregnancy or menstruation

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.