Treatment of Infertility and Clinical Examples
Author/He Shaoshan
Introduction:He Shaoshan (1923-2003), a native of Hangzhou, was the chief physician of gynecology at Hangzhou Traditional Chinese Medicine Hospital, a renowned expert in TCM gynecology, and a nationally recognized veteran TCM practitioner. He came from a family of TCM gynecologists and was the third-generation heir of the He family gynecology in Jiangnan.
Conception is a complex physiological process that requires normal ovulation from the ovaries, the meeting of sperm in the fallopian tubes, the formation of a fertilized egg, and the implantation of the fertilized egg in a suitable endometrium.Common clinical factors contributing to female infertility include ovarian dysfunction, ovulation disorders, fallopian tube obstruction due to inflammation, uterine developmental issues, submucosal fibroids, endometrial tuberculosis, and implantation difficulties.Traditional Chinese Medicine (TCM) has a profound understanding of infertility. As early as the Tang Dynasty, Sun Simiao classified infertility into two categories: “complete absence of children” and “disruption of lineage” (which corresponds to what is now known as primary and secondary infertility). In addition to congenital defects known as the “Five Non-Fertile Women,” the “Yi Zong Jin Jian” states that female infertility is due to damage to the Chong and Ren meridians.
“This may be due to the accumulation of old blood in the uterus, preventing the formation of new blood for conception; or due to cold or heat in the uterus, preventing the reception of sperm for conception; or due to excessive phlegm in the body, obstructing the uterus and preventing conception.”The “Ji Yin Gang Mu” quotes Xue’s saying:“Infertility in women can also be caused by the six excesses and seven emotions, resulting in damage to the ChongRen meridian, or the retention of old blood, affecting the internal organs, or due to coldness in the uterus, excessive qi, and insufficient blood, or heat hidden in the blood, along with spleen and stomach deficiency, which fails to nourish the Chong and Ren meridians.”“There are many causes.“All should be carefully examined for their causes, and treated according to the symptoms, and one can naturally have children.”“Infertility is generally diagnosed and treated based on deficiency and excess.If there is deficiency, one should warm the kidneys, fill the essence, and tonify qi and blood to nourish the Chong and Ren meridians; if there is excess, one should soothe the liver, resolve depression, invigorate blood, eliminate stasis, dry dampness, transform phlegm, and regulate qi and blood to adjust the Chong and Ren meridians.It is also emphasized that when menstruation is irregular, one must first regulate the menstrual cycle.Etiology and PathogenesisMy late father, He Zhixiang, inherited the family tradition and practiced medicine for sixty years, specializing in gynecology, and accumulated rich experience in the diagnosis and treatment of infertility. In my clinical practice alongside my father, I also recognized that simple infertility is rare and easy to treat, while complex infertility with deficiency and excess, cold and heat, is common and difficult to treat. My father believed that the occurrence of infertility is mainly due to dysfunction of the liver and kidneys and the uterus, or disharmony of qi and blood.The kidneys store essence, and the uterine vessels are connected to the kidneys. When kidney qi is abundant, blood can be transformed, and when the heavenly essence arrives, development matures, providing the material basis and driving force for conception. Zhang Jingyue said:“The heavenly essence is the qi that transforms and generates blood; in treating women’s diseases, one should prioritize menstrual blood.”“If kidney qi is insufficient, it cannot vaporize the spleen yang above, nor can it warm the uterine vessels below. The generation of qi and blood is lacking, and it is easy to accumulate phlegm and dampness, leading to obstruction of the uterine vessels and coldness in the uterus, resulting in infertility. If kidney yin is deficient, essence and blood will be depleted, the blood sea will be empty, and the uterine vessels will lose nourishment, thus unable to receive the essence of conception.The liver stores blood and regulates the flow. The liver meridian connects with the Ren meridian and the uterus, serving to regulate the blood sea and the uterine vessels. The liver’s ability to store blood depends on its ability to regulate. When liver qi is smooth, blood vessels will naturally flow. If liver qi is stagnant, qi will be obstructed, leading to blood stasis. Prolonged stagnation can transform into heat, and the combination of stasis and heat can lead to compounded symptoms, resulting in disharmony of qi and blood, and infertility due to the Chong and Ren meridians not being nourished.At the same time, essence and blood are mutually generated, and yin and yang share the same source. If water does not nourish wood, liver blood will inevitably be insufficient, losing its soft nourishment, causing liver qi to rebel, and the rigid wood to act recklessly, leading to discord between blood and qi, making conception impossible. Therefore, Ye Tianshi said:
“Women who are prone to pregnancy often have liver issues; if the liver meridian is affected, menstruation will be irregular, making it difficult to conceive.”“
The uterus is the place for conception and is classified as a unique organ.It resembles a viscera in shape and functions like a zang organ.It has dual functions of both zang and fu.In the relationship between the zang organs and the liver and kidneys, and the meridians and the Chong and Ren, they are closely related.The zang stores essence and qi, retaining without leaking; the fu transforms and processes substances, transforming without storing.The uterine vessels can both retain essence and regulate menstruation, making it ideal for conception.If the uterine vessels fail in their function, they cannot receive the essence for conception.Diagnosis and TreatmentMy father proposed a treatment principle for infertility that involves supplementing deficiencies to support the weak and unblocking excess to eliminate stagnation, selecting methods according to symptoms and applying treatment flexibly.The classics state:“If essence and qi are depleted, it is deficiency.”To tonify deficiency, one should focus on the liver and kidneys. For example, if a young woman has poor development, irregular menstruation, lower back pain, weak legs, fatigue, cold sensations in the lower body, diminished libido, and infertility, the treatment should primarily focus on tonifying the kidneys.One may use nourishing substances such as deer antler, purple ginseng, etc., to fill in, or use herbs that nourish water and yin such as cooked rehmannia, wolfberry, polygonum multiflorum, yam, etc., to nourish, or use warming yang herbs such as aconite, cinnamon, cistanche, morinda root, and dodder to invigorate. Deer antler is a key herb for nourishing the kidneys and strengthening the tendons, and it is very effective in treating infertility.The “Su Wen: Bone Hollow Theory” states:“If the governor vessel is diseased… the woman will be infertile.”This is what Zhang Yinan said:
“The governor vessel and the Chong and Ren meridians arise between the uterus.”“
The governor vessel belongs to the kidneys, maintaining kidney yang.If blood is depleted and nourishment is insufficient, symptoms such as dizziness, palpitations, insomnia, dry mouth, hot palms, shortness of breath, and skin dryness may occur, leading to infertility after prolonged marriage without children. This is often treated by nourishing blood and clearing the liver, using herbs such as angelica, white peony, goji berries, ligusticum, moutan, and stone calamus to nourish.This also aligns with Jingyue’s principle of “to prevent depletion, one must nourish the essence; to unblock, one must fill it.”My father greatly admired Ye Tianshi’s theory that “the liver is the foundation for women” and “treating women’s diseases should focus on the liver.”Thus, in clinical practice, he often emphasized regulating the liver. Qi is the commander of blood; when qi flows, blood flows; when qi is stagnant, blood is stasis. Therefore, if the liver fails to regulate, qi will not flow smoothly, leading to obstruction in the uterine vessels. My father advocated for unblocking the liver as a treatment principle.In the “Medical Truths” by Zongqing and Gao Shizong:
“The methods of unblocking vary; regulating qi to harmonize blood is one way; to make the upward-reversed flow descend, or to make the obstructed flow reach the sides, is also a way; to assist the deficient to unblock, or to warm the cold to unblock.”
And to adjust accordingly.When liver qi is stagnant, blood stasis accumulates, and the uterine vessels are blocked, it is common to use methods that invigorate qi and blood, soothe the liver, and open the meridians, unblocking qi mechanisms, alleviating blood stasis, allowing bad blood to be expelled and new blood to be generated, thus restoring the Chong and Ren meridians for the hope of conception.In clinical practice, if one observes abdominal pain during menstruation, with poor flow, scanty dark blood with clots, breast tenderness before menstruation, mental depression, irritability, and infertility, one should treat with angelica, white peony, ligusticum, safflower, cyperus, sesame, turmeric, and rose to regulate.There are also cases of liver qi stagnation, with wood overpowering spleen earth, spleen deficiency leading to loss of function, internal phlegm and dampness accumulating, descending to obstruct the Chong and Ren meridians, preventing the reception of essence for conception.This is particularly common among rural women who have lived in damp areas, further obstructing the spleen and stomach, damaging yang qi.For cases of abdominal pain during menstruation, continuous leukorrhea, chest tightness, nausea, qi deficiency with poor appetite, pale complexion, and a robust appearance, who have been infertile for years, one should use ginger, dried ginger, white atractylodes, poria, black pepper, deer antler, cinnamon, angelica, ligusticum, bitter orange, and yellow bark to eliminate dampness, clear phlegm, unblock qi mechanisms, open the uterine gates, and restore the Chong and Ren meridians to facilitate the reception of essence for conception.Clinical ExamplesSummarizing my father’s experience in treating infertility, combined with my clinical experience over decades, I believe this condition often presents as types of yin and yang deficiency, kidney deficiency with liver stagnation, cold dampness accumulation, blood stasis, and phlegm obstructing qi stagnation.Both true yin and yang are insufficient; treatment should focus on warming the kidneys and filling the essence.Li Zhongzi said that the kidneys are the foundation of congenital essence. The nurturing of new life relies heavily on abundant kidney qi. Just as a person has a foot, a tree has roots; even if the branches and leaves are withered, as long as the roots are alive, they can regenerate, and flowering and fruiting will naturally not be difficult. Therefore, throughout history, physicians have placed great emphasis on the kidneys in treating infertility.
- Example:
Xu, 30 years old, married for three years without pregnancy, initially diagnosed with scanty light menstruation, lower back pain, weak legs, abdominal distension, insomnia, weak physique, diminished libido, dry throat, constipation, five hearts hot, red tongue with little coating, and cracks, weak and thin pulse. Gynecological examination revealed an immature uterus.Zhang Shanlei Yun:“The mechanism of reproduction is purely endowed by heaven.”This woman had insufficient congenital endowment, kidney qi was not truly abundant, heavenly essence had not yet arrived, both yin and yang were insufficient, and treatment should focus on warming the kidneys and filling the essence, developing the uterus, primarily using the Cistanche and dodder pill with modifications.
Prescription 1:
Deer antler slices, angelica, sweet cistanche, dodder, ligusticum, snake bed seed, fried white peony, goji berries each 10 grams, mugwort, fennel, and ligusticum each 5 grams, taken for two weeks.
Afterward, upon reviewing her dry throat, poor appetite, and constipation, it was determined that she had yin deficiency with internal heat and insufficient fluids, thus should tonify qi and nourish yin, opening the appetite and promoting fluid production, prescribing Ye’s stomach-nourishing decoction with modifications.
Prescription 2:
Codonopsis, fried white peony, Chinese yam, northern ginseng, ophiopogon, angelica each 10 grams, dried tangerine peel 5 grams, fried lily bulb and whole gourd each 12 grams, fried barley 14 grams.
After taking seven doses, her appetite gradually improved, and her bowel movements became smoother. Since her menstrual flow was scanty, with irritability and insomnia, the treatment plan was to “focus on nourishing the lower yin to nourish water,” connecting the heart and kidneys.
Prescription 3:
Cooked rehmannia, salvia each 15 grams, angelica, wine-fried white peony, goji berries, and poria each 10 grams, polygonum multiflorum 15 grams, amber 5 grams, cyperus, sour jujube seed, biota seed, sweet cistanche each 12 grams.
Afterward, based on symptoms, adjustments were made; for menstrual irregularities, use salvia, ze lan, cyperus, and rose; for lower back pain, use ligusticum, dodder, epimedium, and cynomorium; for abdominal distension, use dried tangerine peel, bitter orange, and chicken inner gold. After nine consultations over five months, her menstruation became earlier, with increased flow and bright red color.On the tenth consultation, menstruation stopped for over 50 days, with nausea, lower back pain, thin and slippery pulse, and a positive urine pregnancy test. Gynecological examination showed a smooth and colored cervix, and the uterine body was tilted backward, resembling a 40-day size, diagnosed as early pregnancy.Subsequently, she was given methods to preserve the fetus, and she delivered a healthy boy at full term.Kidney deficiency with liver stagnation, treatment should focus on tonifying the kidneys and regulating the liver.Among infertility cases, those with kidney deficiency and liver stagnation are the most common. The treatment should involve medications that tonify while also unblocking, integrating unblocking into tonification, complementing each other, and achieving quick results.
- Example:
I once treated Wang, 35 years old, who had been married for six years without pregnancy. She had previously used clomiphene to induce ovulation, along with TCM treatment for two years, and later switched to letrozole with little effect. A hysterosalpingography report indicated “polycystic changes in the ovaries,” and a curettage indicated “endometrial hyperplasia.” The patient had menstrual irregularities since puberty, with gradually decreasing flow, breast tenderness before menstruation, and intermenstrual spotting with a coffee-colored discharge, irritability, lower back pain, and poor appetite.Upon examination, she appeared sallow and yellow, with pigmentation on the cheeks in a butterfly shape, a thin physique, hot palms, a dark red tongue, and a pulse that was thin and wiry. It was determined that her kidney water was insufficient, failing to nourish wood, leading to liver qi stagnation, blood stasis, and heat accumulation, causing disharmony between the Chong and Ren meridians, resulting in infertility. The symptoms showed a mix of deficiency and excess, with cold and heat presenting simultaneously, thus the treatment should involve both unblocking and tonifying, clearing the flow and restoring the source.She was prescribed a blood-nourishing and clearing liver formula.
Prescription 1:
Angelica, fried white peony, ligusticum, sweet cistanche, and dried ginger each 10 grams, moutan 6 grams, oyster and calcined stone calamus each 18 grams, green plum flower and fried lentil flower each 5 grams, calcined dragon bone 30 grams, lotus stem 15 grams.
During menstruation, she was given a blood-activating and regulating formula.
Prescription 2:
Angelica, red peony, sesame, prepared cyperus, and poria each 10 grams, peach blossom, safflower, ligusticum, dried tangerine peel, and honey-fried licorice each 5 grams, chicken blood vine 18 grams.
After two months of treatment, liver qi was unblocked, heat was cleared, the blood sea was stabilized, and the uterus was cleared, allowing for smooth new growth. The intermenstrual spotting was corrected, and all symptoms improved, allowing for a focus on tonifying deficiencies.Due to her poor appetite and qi and blood weakness, she was prescribed warming the kidneys and moving the spleen, nourishing essence to promote conception.Medications included clear and fried astragalus, codonopsis, angelica, fried white peony, dodder, fried psoralea, fried nutmeg, and fragrant wood, among others. Following this differential diagnosis and treatment, after three months of medication, her menstruation was regular, and a urine pregnancy test was positive, confirming early pregnancy.Accumulation of phlegm and stasis, treatment should focus on eliminating phlegm and unblocking stagnation.It is essential for qi and blood to flow smoothly. Shen Yaofeng stated:
“The ability to conceive relies entirely on sufficient qi and blood; if one is deficient, there will be no conception; if the body is not deficient but still cannot conceive, there must be another illness.”“Miao Zhongchun attributed wind and cold to invading the uterus, Zhu Danxi attributed hidden heat in the Chong and Ren meridians, Zhang Zihe attributed phlegm accumulation in the uterus, and Danxi stated that women who have not given birth for thirty years must have accumulated blood in the uterus.”“The treatment should involve the use of the Dan Bao Decoction.”
The Dan Bao Decoction is a formula from the “Thousand Gold” that is the first choice for women seeking to conceive. Sun Zhenren emphasized that if used appropriately in clinical practice, it can yield remarkable results.
- Example:
Han, 29 years old, married for four years without pregnancy.Gynecological examination:The cervix was smooth, the uterus was anteverted, normal in size and mobility, with negative findings in both adnexa.Diagnosis:Endometrial inflammation with a secretory phase response, accompanied by infiltration of red and white blood cells.The hysterosalpingography report stated: “The uterine cavity is not significantly deviated, with obstruction at the ampullary region of the right fallopian tube, and the left fallopian tube is patent but not smooth.”The patient had a regular menstrual cycle, with moderate flow, dark purple blood, lower abdominal pain, and occasional dull abdominal pain, with a tongue showing stasis at the edges.She had a robust physique, with few signs of deficiency. As a former swimming pool announcer, she frequently swam, even during menstruation, which led to cold dampness and stasis in the lower body, obstructing the pathways.The “Thousand Gold” states:
“If a woman cannot conceive, it is due to the presence of masses in the uterus; no matter how much one tries to regulate menstruation, if the channels are blocked, it will be futile.”“
Therefore, the Dan Bao Decoction was prescribed to break stasis and eliminate pathogens, clearing the uterine vessels.
Prescription:
Angelica, red peony, deer antler slices, xuanming powder, ligusticum, fried mountain turtle slices each 10 grams, peach kernel, ligusticum, leech, and danpi each 6 grams, xuanming powder 10 grams added later, codonopsis, poria, and ligusticum each 12 grams.
Among them, peach, yellow, leech, and turtle are for unblocking the channels, while deer antler, ligusticum, and angelica are for clearing the land. Codonopsis and poria are for opening the borders, while ligusticum and ligusticum are for promoting the flow.After taking the medicine, she experienced abdominal pain with a small amount of purulent blood, and her weight decreased, feeling increasingly weak.After a brief pause, she resumed treatment, taking a total of 15 doses.After two months, her body recovered, and a follow-up examination showed that the uterine cavity was narrow and slightly deviated, with both fallopian tubes now patent.The obstruction was removed, and attention was given to tonifying; during menstruation, blood-activating and liver-regulating methods were used, while after menstruation, warming the kidneys and strengthening yang were applied, following Shen’s warming kidney decoction and Fu Qingzhu’s transforming water and seeding decoction with modifications.By the end of the following year, she became pregnant for the first time but unfortunately had a miscarriage due to overdue and underwent a curettage.After her second pregnancy, she was given blood-nourishing and fetal-preserving treatments, ultimately delivering a healthy boy at full term.The Dan Bao Decoction is potent and should not be used recklessly; it is not suitable for those with purely solid symptoms.Qi deficiency and accumulation, treatment should focus on nourishing the right and eliminating accumulation.When pathogens stagnate, qi and blood become intertwined, gradually forming masses and accumulating in the uterine gates, leading to infertility. The “Gynecology Jade Scale” states:
“If there are masses between the Ren and Du meridians, then nothing can be applied, as there is an external obstruction.”“
When pathogenic qi lingers, the right qi must be deficient, and one must supplement and unblock simultaneously.
- Example:
I once treated Gao, 29 years old, who had been married for two years without pregnancy. She had experienced menstrual pain for over ten years, with lower abdominal masses that became heavy and painful ten days before menstruation, with moderate menstrual flow, dark purple or black color, and a delay of 2-4 days after menstruation.Her complexion was dark, her skin lacked moisture, her voice was weak, and her movements were slow. The masses gradually increased, and she had a thin physique, with a dark tongue and stasis spots on the edges, and a thin and choppy pulse.Gynecological examination:Subserosal fibroids on the posterior wall of the uterus, approximately 4×4 cm in size. This was due to weak qi and poor blood circulation, leading to qi stagnation and blood stasis, accumulating in the uterine cavity, causing menstrual pain and infertility. The “Jin Gui Yao Lue” states:
“When the nutrient and defensive qi are in harmony, qi will flow; when the great qi turns, the masses will disperse.”“
When the pathogenic qi is real and the right qi is deficient, the treatment should integrate tonification with unblocking, first using methods to soothe the liver and regulate qi, tonifying qi and blood to support the condition, nourishing the right and eliminating accumulation to dissolve masses.
Initial prescription:
Angelica, wine-fried white peony, prepared cyperus, fried lychee seed, and ligusticum each 10 grams, mugwort and light wuyuyu each 6 grams, rose, fennel each 4.5 grams, chicken blood vine and hawthorn each 15 grams.
Later, due to soreness in both legs and qi deficiency, codonopsis, white atractylodes, cooked rehmannia, and ligusticum were added to continue supporting the right qi.
This is based on the principle that “qi and blood are precious and should be abundant; the pathways should be warm and harmonious, and the vital qi should flow smoothly.”By the sixth consultation, menstrual pain had significantly decreased, but the color was still purple with clots, so she was given a modified blood-activating and mass-dissolving decoction.
Sixth prescription:
Blood-stopping agent, leech, prepared myrrh, fennel each 4.5 grams, angelica, curcuma, fried lychee seed, and conch each 9 grams, clear and fried astragalus, summer calamus, and yueju pill each 12 grams, camellia flower 6 grams, and red vine 24 grams.
The leech is used to break stasis, as Zhang Xichun often used it, stating:
“All blood-breaking medicines often harm the qi; only the leech, with its salty flavor, specifically enters the blood without harming the qi, and after taking it, there is no pain, and the stasis blood silently dissipates, making it a true good medicine.”“
It is commonly used for amenorrhea and masses, particularly effective when the pulse is not weak.In subsequent consultations, the medicinal power continued, and timely adjustments were made, waiting for qi and blood to flow smoothly, and the masses to shrink, continuing with warming the kidneys and tonifying the governor vessel to promote conception.Medications included deer antler slices, angelica, ligusticum, white peony, cistanche, dodder, schisandra, raspberry, psoralea, and mugwort. Eventually, she became pregnant, and after a cesarean section, delivered a full-term baby. The fibroids had shrunk to the size of walnuts and were conveniently removed, with pathological examination confirming smooth muscle tumors. The entire treatment lasted 17 months, with 18 consultations and over 100 doses of medication, leading to a successful outcome.