Zhu Nansun: Differentiating and Treating Female Infertility from Both Deficiency and Excess Perspectives

TCM Book Club Issue 1945

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IIntroduction:Have you analyzed female infertility from both deficiency and excess perspectives? In syndrome differentiation, we must also understand the combination of disease and syndrome. This article introduces Zhu Nansun’s experiences in treating female infertility and shares commonly used herbal pairs for infertility treatment. We hope that after reading this article, you will gain a lot. (Editor/Xu Yimeng)

Zhu Nansun’s Experience in Differentiating and Treating Female Infertility

Author/Huang Hui

Female infertility can be categorized into deficiency and excess. For deficiency syndromes, the main treatment is to tonify the liver and kidneys and replenish essence and blood. For excess syndromes, the approach is to clear heat, regulate dampness, soothe the liver, and resolve stasis. The former requires attention to the distinction between liver and kidney yin deficiency and spleen and kidney yang deficiency, seeking the root cause for treatment. The latter should combine syndrome differentiation with disease differentiation, treating the disease and regulating the menstrual cycle to create the opportunity for conception.

1. Deficiency Syndrome Infertility

Deficiency syndromes are often functional diseases, and the main treatment method is to tonify the liver and kidneys and replenish essence and blood. There are two main types:

1. Liver and Kidney Yin Deficiency Type:

Menstrual irregularities or amenorrhea, elevated basal body temperature with a single-phase or high-level biphasic pattern, lower back soreness, dry throat, pulse thin and wiry, tongue dark red with little coating. Master Zhu states: “When kidney qi is abundant and essence and blood are sufficient, the Chong and Ren vessels are flourishing, menstruation occurs regularly, and the two essences meet, then conception can occur.” Therefore, the treatment for this syndrome should focus on regulating the menstrual cycle, nourishing the liver and kidneys, and tonifying blood, using Fu’s Liver Regulating Decoction with modifications.

Herbs used include Dang Gui (Angelica Sinensis), Dan Shen (Salvia Miltiorrhiza), Sheng Di Huang (Rehmannia Glutinosa), Chi Shao (Red Peony Root), Bai Shao (White Peony Root), Chuan Shao (Sichuan Peony), Xuan Shen (Scrophularia Ningpoensis), Sha Shen (Glehnia Littoralis), Mai Dong (Ophiopogon Japonicus), Kan Qi (Corydalis Yanhusuo), Yu Rou Guo (Lycium Barbarum), Huang Qi (Astragalus Membranaceus), Ba Ji Tian (Morinda Officinalis). Start taking after menstruation ends, for a total of 14 doses, and after 1-2 menstrual cycles of treatment, if menstruation normalizes, proceed to the second stage of treatment.

The second stage focuses on tonifying the kidneys to assist conception.

Herbs used include Shu Di Huang (Rehmannia Glutinosa), Gou Qi Zi (Goji Berries), Tu Si Zi (Cuscuta Chinensis), Fu Pen Zi (Rubus Chingii), Huang Shan Yao (Dioscorea Opposita), Yu Rou Guo (Lycium Barbarum), Sang Shen Zi (Mulberry Fruit), Huang Jing (Polygonatum Odoratum), Shi Nan Ye (Baccharis Genistelloides), Ba Ji Tian (Morinda Officinalis), Xian Ling Pi (Epimedium), Zi Shi Ying (Amethyst), etc. Take from the 11th to 18th day after menstruation.

2. Spleen and Kidney Yang Deficiency Type:

Late menarche, irregular or absent menstruation, lack of sexual desire, basal body temperature with a single-phase or low-level biphasic pattern, cold intolerance, loose stools, pulse deep and thin, tongue pale and swollen with a thin white coating and teeth marks.

Master Zhu states: “Kidney qi and essence are the essential material basis for conception, and are also necessary for menstruation to occur regularly, thus regulating the menstrual cycle is crucial for conception.” Therefore, the treatment should also focus on regulating the menstrual cycle, but should emphasize strengthening the spleen and stomach, nourishing blood, and regulating the menstrual cycle, using Xiang Sha Liu Jun Zi Wan combined with Si Wu Tang.

If there is severe loose stool, add Bu Guo Zhi (Psoralea Corylifolia), Huang Shan Yao (Dioscorea Opposita), or Rou Guo (Flesh Fruit), He Zi (Terminalia Chebula). Start taking after menstruation ends, for a total of 14 doses, and after 1-2 menstrual cycles of treatment, if the spleen and stomach are harmonized, qi and blood are sufficient, and menstruation normalizes, proceed to the second stage of treatment.

The second stage is to warm and nourish the Chong and Ren vessels, and replenish essence and marrow.

Use Sheng Yu Tang with Tu Si Zi (Cuscuta Chinensis), Fu Pen Zi (Rubus Chingii), Zi He Che (Cordyceps), Ba Ji Tian (Morinda Officinalis), Lu Jiao (Deer Antler), Qiong Rong (Cistanche Deserticola), etc. Start taking after menstruation ends, for 7-14 doses.

For those with poor sexual function, during the ovulation period, it is advisable to take tonifying spleen and kidney herbs to assist conception, using Dang Shen (Codonopsis Pilosula), Huang Qi (Astragalus Membranaceus), Dang Gui (Angelica Sinensis), Shu Di Huang (Rehmannia Glutinosa), Lu Jiao Pian (Deer Antler Slices), Xian Ling Pi (Epimedium), Xian Mao (Curculigo Orchioides), Ba Ji Tian (Morinda Officinalis), Shi Nan Ye (Baccharis Genistelloides), She Chuang Zi (Cnidium Monnieri), Si Zhi Xiang Fu Wan (Four-Substituted Cyperus Pill). Start taking on the 11th day after menstruation, for 5-7 doses.

2. Herbal Pairs for Deficiency Syndrome Infertility

1. Tu Si Zi (Cuscuta Chinensis) – Gou Qi Zi (Goji Berries):

This is a key herb for liver and kidney yin deficiency type. It is neither warming nor drying, tonifying without being greasy, and is a balanced yin-yang tonic, emphasizing yin nourishment, often paired with Sang Shen Zi (Mulberry Fruit) for enhanced yin-nourishing effects.

2. Shu Di Huang (Rehmannia Glutinosa) – Bai Shao (White Peony Root):

This is a must-have for liver and kidney yin deficiency type. It quietly nourishes, balances liver and kidney, and has significant effects in nourishing water and supporting wood, nourishing yin and blood.

3. Huang Shan Yao (Dioscorea Opposita) – Yu Rou Guo (Lycium Barbarum):

This is commonly used for liver and kidney yin deficiency type. It functions to benefit the kidneys and astringe essence. It is neither hot nor dry, tonifying without stagnation, which is its characteristic.

4. Qiong Rong (Cistanche Deserticola) – Ba Ji Tian (Morinda Officinalis):

This is a key herb for deficiency syndrome infertility. Both enter the Du meridian, often used with qi and blood tonics and yang-supporting herbs, warming and tonifying essence and qi, aiming to harmonize yin and yang based on sufficient yang qi, often adding Bai Zi Ren (Platycladus Orientalis) to nourish yin blood and moisten the intestines.

5. Fu Pen Zi (Rubus Chingii) – Zi Shi Ying (Amethyst):

Commonly used for deficiency syndrome infertility. It is warming without being drying, a product that contains both yin and yang, warming the uterus, tonifying the kidneys, and benefiting essence and blood.

6. Zi He Che (Cordyceps) – Lu Jiao Pian (Deer Antler Slices):

This is a tonic for spleen and kidney yang deficiency type after menstruation. It is a substance with blood and flesh, sweet and salty, warming and nourishing, significantly tonifying blood and filling the Du meridian.

7. Ba Ji Tian (Morinda Officinalis) – Lu Jiao Pian (Deer Antler Slices):

This is a key herb for spleen and kidney yang deficiency type. It is a substance with blood and flesh, entering the Chong, Ren, and Du meridians, warming and tonifying the Chong and Ren, benefiting the kidneys and supporting yang.

8. Xian Mao (Curculigo Orchioides) – Xian Ling Pi (Epimedium):

Due to its warm and spicy nature, it tonifies the Mingmen and promotes yang, making it the first choice for supporting yang and promoting ovulation in spleen and kidney yang deficiency type. However, it should be used cautiously in those with yin deficiency.

9. Shi Nan Ye (Baccharis Genistelloides) – She Chuang Zi (Cnidium Monnieri):

This is a key herb for spleen and kidney yang deficiency type, also selected for liver and kidney yin deficiency type. It warms the kidneys, strengthens yang, and promotes ovulation, especially for those with low sexual desire, increasing libido. Due to its spicy and warm nature, it should be used for 5-7 days and not for prolonged periods.

10. Xian Ling Pi (Epimedium) – Shi Nan Ye (Baccharis Genistelloides):

This is a key herb for liver and kidney yin deficiency type, also commonly selected for various types of infertility. It functions to warm the kidneys and support yang, but is warming without being hot.

11. Dang Shen (Codonopsis Pilosula) – Huang Qi (Astragalus Membranaceus):

This is often used for spleen and kidney yang deficiency type. It functions to invigorate the middle qi, especially for those with elevated basal body temperature and luteal phase dysfunction, often used in combination with yang-supporting herbs to tonify qi and support yang.

12. Fu Zi (Aconitum Carmichaelii) – Rou Gui (Cinnamon):

This is used for spleen and kidney yang deficiency type. It has a warm and spicy flavor, warming the uterus and tonifying the Mingmen fire, promoting the generation of yang and the growth of yin.

3. Excess Syndrome Infertility

Master Zhu believes that excess syndrome infertility is often due to the three evils of emotional disturbances, six excesses, and external injuries, which may damage the Chong and Ren vessels, leading to damp-heat accumulation; or obstruction of the uterine vessels, stagnation of liver qi; or accumulation of masses and stasis of blood. There are three main types:

1. Evil Damaging Chong and Ren, Damp-Heat Accumulation Type:

Dysmenorrhea, breast tenderness before menstruation, menstrual irregularities, abnormal vaginal discharge, gynecological examination shows thickened and tender adnexa, uterine and fallopian tube oil contrast shows patency but not smooth, pulse thin and rapid, tongue red with a thin yellow greasy coating. In modern medicine, chronic pelvic inflammatory disease falls under this type. Master Zhu believes that chronic pelvic inflammatory disease is a common gynecological disease, often caused by damp-heat evil invading the body, causing disharmony of qi and blood, and difficulty in conception. Therefore, the main treatment method is to clear heat, regulate dampness, and soothe the liver to regulate the menstrual cycle.

Herbs used include Sheng Di (Rehmannia Glutinosa), Dan Pi (Moutan Cortex), Pu Gong Ying (Dandelion), Hong Teng (Sargentodoxa Cuneata), Bai Jiang Cao (Patrinia Scabiosaefolia), Di Ding Cao (Euphorbia Humifusa), Yu Jin (Curcuma Aromatica), Chai Hu (Bupleurum Chinense), Yuan Hu (Corydalis Yanhusuo), Liu Ji Nu (Liu Jun Zi), Zhi Mu (Anemarrhena Asphodeloides), Huang Bai (Phellodendron Amurense). If there is breast tenderness before menstruation, add Chuan Lian Zi (Toosendan Fructus), Zhi Xiang Fu (Cyperus Rotundus). If menstrual flow is scant, add Chi Shao (Red Peony Root), Dan Shen (Salvia Miltiorrhiza), Dang Gui (Angelica Sinensis). If there is a urinary tract infection, add Bi Yu San (Biyu Powder), Hai Jin Sha (Lygodium Japonicum), Che Qian Zi (Plantago Asiatica). If there is constipation, add Yue Ji Hua (Rosa Rugosa) or Da Huang (Rhubarb).

From the 11th to 18th day after menstruation, add Lu Lu Tong (Lonicera Japonica), Suo Luo Zi (Saururus Chinensis), Guang Di Long (Earthworm), Liuxing Zi (Liu Xing Zi) to open the meridians.

2. Uterine Vessel Obstruction, Liver Qi Stagnation Type:

Long-term infertility, lack of sexual desire, breast tenderness before menstruation, obesity with abdominal pain, gynecological examination shows significant thickening of adnexa, uterine and fallopian tube contrast shows obstruction, pulse thin or deep and thin, tongue dark with a greasy coating. In modern medicine, this type corresponds to fallopian tube obstruction. Master Zhu believes that if both fallopian tubes are completely obstructed, treatment is difficult, while the vast majority of those who can be cured have incomplete obstruction or pseudo-obstruction.

The treatment focuses on regulating qi, relieving stagnation, and opening the meridians. Clinically, based on the severity of the condition, the following methods are used:

(1) Clearing Method: Suitable for short duration of illness, with significant heat evil, aiming to clear heat, regulate qi, and open the meridians, using Dan Shen (Salvia Miltiorrhiza), Dan Pi (Moutan Cortex), Chi Shao (Red Peony Root), Zhi Xiang Fu (Cyperus Rotundus), Chai Hu (Bupleurum Chinense), Chuan Lian Zi (Toosendan Fructus), Liuxing Zi (Liu Xing Zi), Suo Luo Zi (Saururus Chinensis), Lu Lu Tong (Lonicera Japonica), Guang Di Long (Earthworm), Chang Pu (Acorus Tatarinowii).

If there is constipation, add Yue Ji Hua (Rosa Rugosa), Quan Gua Lou (Trichosanthes Kirilowii), if there is significant qi stagnation, add San Leng (Sparganium Stoloniferum), E Zhu (Curcuma Zedoaria).

(2) Warming Method: Suitable for long duration of illness, inflammation has been eliminated, but the meridians are not open, aiming to warm the meridians and open the channels, using Chai Hu (Bupleurum Chinense), Chuan Lian Zi (Toosendan Fructus), Zhi Xiang Fu (Cyperus Rotundus), Liuxing Zi (Liu Xing Zi), Suo Luo Zi (Saururus Chinensis), Lu Lu Tong (Lonicera Japonica), Guang Di Long (Earthworm), Chang Pu (Acorus Tatarinowii), Xiao Hui Xiang (Foeniculum Vulgare), Chen Xiang Fen (Aquilaria Sinensis Powder). All should be taken during the menstrual period for 7-10 doses.

3. Mass Accumulation, Blood Stasis Type:

Progressively worsening dysmenorrhea, menstrual irregularities, anal distension, gynecological examination shows nodules in the fornix or ovarian masses, pulse thin and wiry, tongue dark purple. In modern medicine, this type corresponds to endometriosis and chocolate cysts. This is due to blood stasis, with retained blood forming masses, leading to blood stasis and mass accumulation. The treatment aims to resolve stasis, break up masses, and regulate the Chong and Ren vessels, using Shao Fu Zhu Yu Tang with modifications.

Herbs used include Dan Shen (Salvia Miltiorrhiza), Chi Shao (Red Peony Root), Chai Hu (Bupleurum Chinense), Yuan Hu (Corydalis Yanhusuo), Puhuang (Typhae Pollen), San Leng (Sparganium Stoloniferum), E Zhu (Curcuma Zedoaria), Shi Da Chuan (Stone Breaker), Liu Ji Nu (Liu Jun Zi), Dan Pi (Moutan Cortex), Chuan Lian Zi (Toosendan Fructus), Ru Xiang (Frankincense), Mo Yao (Myrrh), Di Long (Earthworm), Xue Jie Fen (Dragon’s Blood Powder). Continuous use for 2-3 months.

For those with excessive menstrual flow, during menstruation remove San Leng (Sparganium Stoloniferum), E Zhu (Curcuma Zedoaria), add San Qi Fen (Panax Notoginseng Powder), and use Puhuang (Typhae Pollen) roasted to charcoal, or add Xian He Cao (Agrimonia Pilosa), Yi Mu Cao (Leonurus Japonicus) to promote hemostasis and astringency.

Master Zhu states: Patients who conceive after treatment should tonify the kidneys and stabilize the fetus, otherwise there is a risk of miscarriage or threatened abortion.

4. Herbal Pairs for Excess Syndrome Infertility

1. Pu Gong Ying (Dandelion) – Hong Teng (Sargentodoxa Cuneata):

This is the first choice for treating acute and chronic pelvic inflammatory disease and fallopian tube obstruction. It is bitter and cold, with the ability to clear heat and detoxify, disperse masses and reduce swelling, often paired with Bai Jiang Cao (Patrinia Scabiosaefolia) to enhance its efficacy, and can also resolve stasis and disperse masses.

2. Chai Hu (Bupleurum Chinense) – Yuan Hu (Corydalis Yanhusuo):

This is used for pelvic inflammatory disease and mild cases of fallopian tube obstruction. It functions to soothe the liver, relieve depression, regulate qi, and alleviate pain, and also has the ability to open and prevent obstruction.

3. Chuan Lian Zi (Toosendan Fructus) – Lu Lu Tong (Lonicera Japonica):

This is a must-use for treating fallopian tube obstruction. It is often paired with Suo Luo Zi (Saururus Chinensis) and Liuxing Zi (Liu Xing Zi), functioning to soothe the liver, regulate qi, and invigorate blood to open the meridians.

4. Lu Lu Tong (Lonicera Japonica) – Guang Di Long (Earthworm):

This is a key herb for treating fallopian tube obstruction and hydrosalpinx. It functions to clear heat, promote diuresis, and open the meridians.

5. Ma Bian Cao (Verbena Officinalis) – Liuxing Zi (Liu Xing Zi):

This is specifically used for hydrosalpinx. It invigorates blood, opens the meridians, and promotes diuresis, and can also be used with Shi Jian Chuan (Stone Breaker) to enhance its efficacy.

6. Xiao Hui Xiang (Foeniculum Vulgare) – Chen Xiang Fen (Aquilaria Sinensis Powder):

This is a must-use for treating cold-type fallopian tube obstruction. It regulates qi, opens the meridians, and warms the kidneys to dispel cold. Due to its spicy and warm nature, it is easy to injure fluids and yin, generally used for 5 days during menstruation and then stopped.

7. Shi Chang Pu (Acorus Tatarinowii) – Zhi Nan Xing (Arisaema Erubescens):

This is a key herb for phlegm-damp obstruction infertility. It functions to transform phlegm, open the orifices, and awaken the mind, specifically treating phlegm-damp obstruction of the meridians. Each menstrual period, add Shi Nan Ye (Baccharis Genistelloides) to enhance its phlegm-resolving and meridian-opening effects, while also warming the kidneys and promoting yang.

8. Shi Da Chuan (Stone Breaker) – Liu Ji Nu (Liu Jun Zi):

This is used for endometriosis and ovarian cysts with heat symptoms. It has the ability to clear heat, promote diuresis, and open the meridians to disperse masses.

9. Pu Huang (Typhae Pollen) – Chi Shao (Red Peony Root):

This is a must-use for endometriosis. It functions to invigorate blood, cool blood, and disperse stasis.

10. San Leng (Sparganium Stoloniferum) – E Zhu (Curcuma Zedoaria):

This is a must-use for endometriosis. It functions to break blood stasis, resolve stasis, and relieve pain. As it belongs to the category of blood-breaking and dispersing herbs, it may harm the original qi, so it should be used cautiously in deficiency syndromes.

11. Ru Xiang (Frankincense) – Mo Yao (Myrrh):

This is the first choice for dysmenorrhea associated with endometriosis. It functions to invigorate blood, disperse stasis, reduce swelling, and relieve pain, treating both qi and blood, with significant analgesic effects.

12. Xue Jie (Dragon’s Blood) – San Qi (Panax Notoginseng):

This is a must-use for endometriosis with heavy menstrual flow. It has astringent and dispersive properties, with the ability to stop bleeding, resolve stasis, and relieve pain, and has the characteristic of stopping bleeding without leaving stasis.

13. Ji Sheng (Parasitic Plant) – Si Gua Luo (Luffa Cylindrica):

This is used for cases of fallopian tube patency but not smooth. It tonifies while also promoting passage, often used with Sang Zhi (Mulberry Branch) to tonify the liver and kidneys while opening the meridians.

14. Zhi Mu (Anemarrhena Asphodeloides) – Huang Bai (Phellodendron Amurense):

This is used for pelvic inflammatory disease with severe damp-heat, and kidney yin being scorched. It functions to clear damp-heat from the lower jiao and nourish the kidneys while draining fire.

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