TREATING INFERTILITY WITH CHINESE MEDICINE By Cindy Micleu, L.Ac. Throughout the menstrual cycle, changes in repro- Hunt, a research biologist at Washington State ductive physiology are matched by energetic changes, University, has shown that repeated small exposures to with fluctuations of yin, , qi, and blood reflected in these chemicals found in everyday life specifically target the various phases of the cycle. Examining these the reproductive system and can cause severe genetic changes in the follicular, ovulatory, luteal, and menstru- abnormalities in egg cells.1 al phases, allows for a detailed view of a woman's repro- Statistics show one in eight people in the U.S. have ductive cycle. In the diagnosis and treatment of infertili- an infertility problem (Resolve: The National Infertility ty 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 use the normal functioning of each specific stage of the men- of Chinese medicine in conjunction with ART (assisted strual 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 refer monly employed in cases of "unexplained infertility," a patients to Chinese medicine. Patients are often spending diagnosis frequently given when there are no specific a great deal of money on fertility technology, with expo- problems detected in a Western sure to high levels of chemical hor- medicine infertility evaluation. In CHONG RELEASE FORMULA mones. There is also the -term these cases, the ovarian follicles are Spatholobus Ji Teng ...... 15% emotional stress inherent in the developing normally on ultrasound process. For many reasons, Chinese Mimosa Tree Bark Huan Pi ...... 15% evaluation, hormone levels are in medicine practitioners are in a White Peony Bai ...... 12% normal range, and ovulation seems unique position to be important and to be occurring properly. Pelvic Codonopsis Dang Shen ...... 12% effective health care providers for organs are structurally sound and White Atractylodes Bai ...... 12% these patients. free of endometriosis and fibroid Angelica Sinensis Dang Gui ...... 10% tumors, the endometrial lining Red Peony Chi Shao ...... 10% TREATING FEMALE builds adequately, and sperm Ligusticum Chuan ...... 6% INFERTILITY THROUGH parameters are within normal range. Persica Seed ...... 5% THE MENSTRUAL Advanced age is often the assumed Carthamus Hong Hua ...... 3% CYCLE problem in these infertility cases. Menstrual Phase In 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 is Sometimes 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 menstrual problems conceiving. In fact, women in their 20's have bleeding, not just spotting. If the period begins in the the 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 the duction, 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 the fatigue, 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 the clear diagnostic imbalance, though their liver and/or kid- loss of blood during menstruation, the ren and chong ney 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 their been 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 qi medicine point of view, researchers are increasingly sus- and blood flow, while problems that occur or are worse picious of the role that environmental toxins play on ris- towards the end of the menses are generally associated ing infertility rates. Referred to as "endocrine disruptors" with blood deficiency. because they interfere with hormone function, some Treatment of infertility during the menstrual phase chemicals such as phthalates and bisphenol A (in many focuses on clearing any stagnation that may impede the plastics) have been implicated in rising rates of cancer, quality and movement of qi and blood in the following miscarriage and both male and female infertility. Patricia 2 INFERTILITY cycle. Clearing blood stasis facilitates the complete dis- Secondarily, heat may be a problem during this charge of menstrual blood so that the new endometrial phase, as it easily causes damage to the yin, and can lining can grow on a smooth, clean base. Some practi- enter the blood prompting it to move recklessly at ovu- tioners will use herbs to "flush" the uterine lining blood lation or menstruation. Heat can cause follicles to grow during menstruation, encouraging the complete dis- too quickly, resulting in poor egg quality, and may cause charge of the endometrium, even if there are no overt early ovulation and the shortening of the entire menstru- symptoms of blood stasis. But in particular, if there are al cycle. signs of stasis such as clotting, cramping, or irregular Heat in the follicular phase is commonly due to yin bleeding, this may be a particularly useful strategy. deficiency or stagnation of the heart and liver qi. Patients A base formula used during the menstrual phase is with fertility problems frequently experience a great deal Chong Release Formula ( Wei Tao Hong Si of stress when month after month they are unable to con- Tang). Shu di was omitted from the traditional formula ceive. In these cases, heat from stagnation may disturb due to its cloying nature, while herbs to support the the steady building of yin and blood, and is often seen in spleen were added to reinforce the ability of the qi to upward spikes in the basal body temperature. expel the blood effectively and to support the production Nourish Ren & Chong Formula (Jia Wei Gui Shao of blood after the loss during menstruation. Di Wan) is a very effective formula for the follic- ular phase, nourishing both the yin and blood. The heart Follicular Phase and liver may be addressed with The follicular phase begins on NOURISH REN & CHONG FORMULA additions or modifications to the day 1 of the menstrual cycle when formula. Chinese Yam Shan ...... 12% new follicles, containing eggs, With the use of yin and blood begin their growth. Clinically, we Angelica Sinensis Dang Gui ...... 12% tonifying herbs, fertility signs often generally begin support of this White Peony Bai Shao ...... 12% show clear improvement. Long or phase after the major menstrual Cured Rehmannia Root Shu Di Huang. .10% short follicular phases regulate, cer- blood flow is over, usually around Cornelian Cherry Shan Zhu ...... 9% vical mucus increases, menstrual day 4. Lycium Fruit Gou Qi Zi ...... 9% blood quantity and quality improves, During the follicular phase, Salvia Dan Shen ...... 8% and basal body temperature charts the hypothalamus and the pituitary Gardenia Zhi Zi...... 8% become more even. Correspondingly, interact, stimulating the pituitary Tree Peony Root Bark Mu Dan Pi ...... 5% western lab tests often show to release FSH (follicle stimulating improvement in follicle and endome- Poria Ling ...... 5% hormone), that in turn stimulates trial lining development. Asian Water Plantain Ze ...... 5% the maturation of the ovarian folli- Ovulatory Phase cles. One of these follicles will Tangerine Peel Pi ...... 5% When the main developing follicle grow to become the largest, or dom- becomes large enough and estrogen reaches a certain inant follicle, and will release its egg at ovulation. level, ovulation will occur. Prior to ovulation, the hypo- The regeneration of the endometrium, or uterine - thalamus and pituitary gland again play a major role as ing, begins about 2 days after the onset of menstruation, LH (luteinizing hormone) is released. This causes the even though menstrual bleeding still continues. This "LH surge" which occurs about 24 hours prior to ovula- process includes tissue repair of the uterus where the lin- tion and is detected by an ovulation predictor kit. ing has shed, as well as the development of estrogen and In a normal, healthy ovulation, the basal body tem- progesterone receptors in the new tissue. Estrogen is the perature chart will show a quick rise in temperature with dominant hormone during this phase, and as the levels the LH surge, and temperatures will then stay relatively gradually rise, proliferation of the endometrium and its high throughout the second half of the cycle. This is dense vascular network is stimulated. It also causes the indicative of the quick change from yin dominance in cervix to produce cervical fluid. the follicular phase to yang dominance in the luteal From a Chinese medical perspective, follicle devel- phase. Ovulation itself depends on the yin and blood opment is a yin process, dependent on yin, blood and being at their fullest, and the ensuing transformation of essence. In the follicular phase, the Ren and Chong are full yin to yang. filling and the yin and blood are building as the follicles Yin at its fullest corresponds to the secretion of ovu- grow. Any tendency to yin and/or blood deficiency latory cervical mucus and follicle growth at its peak. As should be supported during this time in particular. Yin it changes to yang, activity and movement are expressed and blood deficiency affecting fertility may manifest as the dominant egg bursts forth from the follicle. This with poor follicular development, thin endometrial lin- process of ovulation is dependent on the strength and ing, or decreased cervical mucus. fullness 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 um rich in hormones and nutrients and maintaining a may be seen in long cycles, in basal body temperature healthy environment for implantation. It also inhibits the charts 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 the when ovulation predictor tests show no clear ovulation. higher basal body temperatures during this time. Some ovulatory problems such as The luteal phase is dominated polycystic 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 of yin and Mimosa Tree Bark He Huan Pi ...... 12% plicated and require specific herbal blood. In order for implantation to treatment to address the particular Spatholobus Ji Xue Teng ...... 11% occur, the uterine lining must be problem. 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, a bao mai, the collateral connecting Cuscuta Tu Si Zi ...... 9% very yin environment in which the the heart to the uterus. The bao mai Dipsacus ...... 9% fertilized egg burrows until it is is one of the pathways by which the White Peony Bai Shao ...... 8% completely buried by the end of the action of the heart qi and blood cycle. Poria Fu Ling ...... 7% descend to the reproductive organs, Support of this phase generally Red Peony Chi Shao...... 7% keeping them nourished and facili- begins with herbs that tonify the tating movement. The health of the Ligusticum Chuan Xiong ...... 5% yang and qi, often including herbs heart and liver are key energies in Carthamus Hong Hua...... 5% to support the yin and/or blood as the activity and vitality of transi- 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 the cycle can be inhibited by stagnation of qi, blood, and/or foundation or root of the yang, and to protect the yin phlegm. 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 blood this transitional movement. were already well nourished in Mobilize Essence Formula (Fu SUPPORT FORMULA the follicular phase, and cleared Ren Bu Yin Pian) is used for mid-cycle Polygonum Vine Jiao Teng...... 10% of stasis in the menstrual phase. support. The formula invigorates the In the luteal phase it is appropri- Chinese Yam Shan Yao...... 10% blood and removes stasis, while pro- ate to continue this support of Cuscuta Tu Si Zi ...... 10% moting a healthy yin foundation and yin and blood. the ability for yang to mobilize at ovu- Angelica Sinensis Dang Gui ...... 9% Problems of the luteal phase lation. Herbs during this phase of the Dipsacus Xu Duan...... 9% may be seen in significant drops cycle are generally administered begin- White Peony Bai Shao ...... 9% in basal body temperatures in ning about 3 days before ovulation, or Codonopsis Dang Shen ...... 8% the second half of the cycle, in when ovulation should ideally occur, White Atractylodes Bai Zhu ...... 8% progesterone insufficiency, until 2 days after ovulation. Poria Fu Ling ...... 8% problems with implantation, and the tendency to miscarriage. Luteal Phase Eucommia Bark ...... 7% Although pre-menstrual stagna- After the egg is released at ovulation, Lycium Fruit Gou Qi Zi ...... 6% tion is not itself an indicator of the sperm and egg travel to meet in the Bupleurum Root Chai ...... 6% an infertility problem, it may fallopian tubes, where a successful well compound the difficulty, so sperm will penetrate and fertilize the egg. The egg must addressing the liver may be employed as a secondary be fertilized in the fallopian tubes within about 12 hours treatment principle. of ovulation, then it continues moving to the uterus to Yuan Support Formula (Jia Wei Jian Tang) implant in the endometrial lining. Implantation begins supports the luteal phase well by tonifying and invigor- about 7 days after ovulation. The necessity of healthy ating the yang and the spleen qi. The formula has been yang to support movement and activity in this phase is modified with herbs to support the yin and blood, to clear. move liver qi stagnation, and calm the spirit. After ovulation, the corpus luteum is formed at the

4 INFERTILITY

ENDNOTE 1Hunt, PA, et. al., The Bisphenol A Experience: A Primer for the Analysis of Environmental Effects on Mammalian Reproduction, Biol Reprod, May 20, 2009.

CINDY MICLEU, L.Ac., is the founder and director of the Jade Institute, located in Seattle, Washington. The Jade Institute provides educational programs for Oriental Medicine practitioners, emphasizing clinical relevance and a collaborative approach to health care. For more information you can visit the Jade Institute website at www.jadeinstitute.com

1) Menstrual Phase 2) Follicular Phase Chong Release Formula Nourish Ren & Chong Formula (Jia Wei Tao Hong Si Wu Tang) (Jia Wei Gui Shao Di Huang Wan)

l Yin and blood gradually decrease l Yin and blood gradually build to fill the ren l Ren and chong become empty and chong l Ovarian follicles are growing, estrogen levels l Blood should be fully expelled and are rising stagnation in the uterus cleared l Yin and blood are dominant l Basal body temperatures (BBT) stay relatively low

3) Ovulatory Phase 4) Luteal Phase Mobilize Essence Formula Yuan Support Formula (Fu Ren Bu Yin Pian) (Jia Wei Jian Gu Tang) l Follicles have been developing and largest l Progesterone becomes important prepares to release egg l Qi and yang are dominant l Growth of yin must be "exuberant" in order l Yin and blood remain important as material to induce the yang movement of ovulation basis of yang and qi l Ovulation occurs with a quick change of l Fertilization and conception are dependent yin to yang on dynamic action of yang l BBT temperatures rise quickly l BBT temperatures are ideally at least 4/10 degree higher than in follicular phase

Pre-Menses l Yang and qi should be strong and full, and move freely l As qi builds, stagnation may occur; heat easily generates from stagnation l A strong foundation of yin is necessary to root yang l Yang heat may enter the blood l Typical formulas address heat and liver qi stagnation, such as Free & Easy Wanderer Plus (Jia Wei Yao San)

©2009CINDY MICLEU, HERBAL MEDICINE PRESS.