Case Study 2: A case of Infertility
by Danny T. Siegenthaler (Kurrajong Natural Medicine Centre)
Introduction
According to Maciocia (1998, p. 691) infertility is defined as “…the inability to produce offspring in a woman who has been trying for two years, who has a normal sexual life and, of course, whose partner has normal reproductive function”. If a woman has never been pregnant and has been trying to fall pregnant for 2 or more years than this is considered primary infertility, if however a woman has previously been pregnant (even if she miscarried) and has been trying for 2 or more years than this is considered secondary infertility.
A woman’s optimal period of fertility is between 18 and 35 years of age, during this time there are between 1,000,000 (18 yr) and 100,000 (35 yr) follicles left in the woman’s ovaries (Annon., 2010). However, many factors can hinder or interfere with a woman’s ability to become pregnant, including endometriosis, pelvic inflammatory disease, absence of ovulation, etc.
Both Western medicine (WM) and traditional Chinese medicine (TCM) recognise infertility as a gynaecological disorder, however, the methods of diagnosis and treatment are considerably different. IVF and assisted reproduction therapy (ART) are preferred choices of treatment in WM while in TCM, Chinese herbal medicine and/or Acupuncture are the treatments of choice.
Traditional Chinese Medicine (TCM) and Biomedical Aetiology and Treatment of Infertility
TCM:
Causes of Infertility include: constitutional weakness, overwork, excessive physical work, excessive sexual activity at an early age, invasion of cold, dietary inadequacies, any of which can result in either an empty or full condition. According to Maciocia (1998, pp. 695-696) infertility is either an empty or full condition, but can manifest in an individual as a combination of both full and empty patterns (Table 1). For example, a woman may have an underlying Kidney deficiency as well as Liver Qi stagnation, which may lead to Blood becoming stagnant.
| Empty | Full |
| Kidney-Yang deficiency | Cold in Uterus |
| Kidney-Yin deficiency | Dampness in the Lower Heater |
| Blood deficiency | Blood-Heat |
|
| Stagnation of Qi |
|
| Stagnation of Blood |
Table 1 Lists the empty and full TCM patterns associated with female infertility as described by Maciocia (1998, pp. 695-696)
Lyttleton (2004, p. 88) takes a different perspective, viewing functional infertility according to menstrual cycle phases. She describes the main categories of infertility to include Kidney deficiency, Heart and Liver Qi stagnation, Blood stagnation, and Phlegm-Damp accumulation, which are also described by Zhou and Qu (2009).
Treatment in TCM is primarily herbal (Zhou & Qu, 2009). There is no single herb or formula that is considered as the formula of choice, rather some 100 herbs are suitable and dozens of formulae have been used (Zhou & Qu, 2009). This is also reflected in part by Maciocia (1998, pp. 697-734), who also lists many different herbal approaches and a range of different formulae, but in addition, he like Lyttleton, also suggest using acupuncture points for treating the various types of infertility. Similarly, in her book, Lyttleton (2004) describes several herbal formulae to treat the infertility, but unlike Zhou and Qu (2009), also provides formulae of acupuncture points to treat the various TCM patterns associated with infertility.
Biomedical:
According the Merck Manual (Rebar, 2008) Infertility is the inability of a couple to conceive after 1 year of unprotected intercourse. The causes of infertility according to Western Medicine (WM) include: Fallopian tube blockage, polycystic ovarian disease, inadequate luteal syndrome, endometriosis, pelvic inflammatory disease, etc (Jane Lyttleton, 2004, p. 87). The majority of cases relate to the hypothalamic-pituitary-ovarian axis and may be listed in decreasing order of occurrence as follows (Annon., 2010; Maciocia, 1998, p. 735):
• Hormonal factors of ovulation (41%)
• Fallopian tube abnormalities (32%)
• Uterine abnormalities/factors (eg: fibroids or abnormalities of shape) (16%)
• Cervical factors (4.7%)
• No apparent causes (5%)
Treatment of Infertility
Biomedical
Biomedical treatment of infertility primarily focuses on IVF and/or ART. According to Lim (2010) causes of infertility include: sperm defects or dysfunction, ovulation failure (amenorrhoea or oligomenorrhoea), tubal infective damage, unexplained infertility, endometriosis (causing damage), coital failure or infrequency, cervical mucous defects or dysfunction, uterine abnormalities (eg: fibroids or abnormalities of shape). Depending on the underlying cause(s), infertility may be treated with Clomiphene, Metformin 500 tds. Surgery – laparoscopic ovarian drilling, OI using FSH, or IVF (Lim, 2010).
TCM
Traditional Chinese medicine utilises herbal medicine and/or acupuncture to treat the underlying cause of infertility. Once male infertility has been ruled out as a contributing factor, focus is placed on the female reproductive cycle.
In the author’s experience, focus should first be on the menstrual cycle. Any problems associated with menstruation and ovulation needs to be addressed primarily. Once ovulation can be confirmed, the menstrual cycle is within the normal length and the pre-menstrual and menstrual phases are non-problematic, the woman normally falls pregnant within 3-4 months.
This case study clearly illustrates this; Pam presented with several conditions: Infertility, Premenstrual Syndrome and Migraines, which were related (in terms of TCM pathology) and required treatment.
Patient History, Diagnosis (both TCM & Biomedical), Treatment Principles (TCM) and Treatment (TCM)
Medical History & Presenting Symptomatology
Female, age 34 presented with:
1. Infertility
2. PMT
3. Migraine Headaches
First Consultation: May 2003
1) Infertility:
• Pam has been trying to fall pregnant for several years (Infertility); took a course of fertility drugs, but had no result. NB: Husband’s sperm was checked and found to be normal.
2) PMT (up to 2 weeks prior to period):
• Irritability
• Mood Swings
• Some Depression
• Bloating
• Some Fluid Retention
• Tender breast
3) Period (Currently day 7):
• Regular cycle
• Intermittent flow
• Small clots (about 10-20¢ in size)
• Mild aching in lower abdomen during the period
4) Migraine like Headaches: - (taking Mercindol to ease the Pain)
• Headaches every 2 days or so
o Mild version is behind the eyes, above & below the eye
o Severe version (Migraine) is 1-Sided (left or right), with Nausea; starting at back of Neck moves over top or side of head to forehead.
Other S+S:
• Lower back pain
• L/s. knee aches when walking
• Gets cold feet easily
• Postural dizziness
• Libido is up/down
• Occasional blurring of vision
• Good appetite
• Dreams frequently & vividly, but no nightmares
• Tinnitus
• Vertigo
• Epigastric distension & nausea relieved by eating
• T: Red body with Spots over Tip
• P: Rapid & Wiry
Biomedical Diagnosis and Aetiology
Functional infertility of unexplained cause. The patient was referred by her gynaecologist after no obvious cause could be established and the use of infertility drugs was unsuccessful.
Case Specific WM Diagnosis
1) Infertility of unknown cause.
TCM Treatment Principles
1) Kid Yang Xu
2) Liv. Qi Stagnation (Pre-mens) leading to Yang rising
3) Liv. Xue Stagnation (During mens)
4) Liv Xue Xu (Post-mens)
Thus, (i) tonify and warm Kidney Yang, warm & strengthen the Uterus and tonify Jing, and (ii) nourish liver Blood, disperse Liver Qi & Xue Stagnation and pacify the Liver.
TCM Herbal Prescription
Pam was treated over a seven-month period with a range of different formulae at different times of her menstrual cycle and in accordance to presenting symptomatology. To detail this on a treatment-by-treatment basis in this case study is not possible due to the restrictive word limit. Therefore, the case is summarised and illustrated in brief.
Key Formula Combination used to treat PMT and infertility include:
1) Shi Quan Da Bu Wan & Xiao Yao San (or Jia Wei Xiao Yao San, if Headache) - Leading up to period
2) Tao Hong Si Wu Wan & Xiao Yao San (or Jia Wei Xiao Yao San, if Headache) - From day 1 to end of period, or
3) Shao Fu Zhu Yu Tang & Xiao Yao San (or Jia Wei Xiao Yao San if Headache) From day 1 to end of period
4) Ba Zhen Tang & Ba Ji Yin Yang Wan from end of period to ovulation
5) You Gui Wan & Ba Zhen Tang - From ovulation to start of PMS, if no PMS, up to day 1, if PMT use Xiao Yao San instead of Ba Zhen Tang.
Note: Pam was given both Jia Wei Xiao Yao San and Xiao Yao San and was instructed to use Jia Wei Xiao Yao San if she felt she was getting a headache, but if not, to use Xiao Yao San instead.
Pam was primarily treated using TCM herbs and did not receive any Acupuncture, however, she came to see me for Acupuncture, if she had a Migraine (or felt one coming on) and this was treated using CO.4 & Liv.3. The needles were retained until the Migraine had subsided.
Treatment Rationale
Chinese herbal formulae:
Shi Quan Da Bu Wan consists of Ba Zhen Tang (Blood and Qi tonic) and two additional herbs that tonify the Kidney Yang i.e.: Rou Gui and Huang Qi. It is a gentle, slightly warming formula that aims to primarily tonify Blood and Qi.
Xiao Yao San is one of the major formulae used to treat PMT due to Liver Qi Stagnation. In addition, it also nourishes Blood and tonifies the Spleen.
In combination these two formulae work well together premenstrually to disperse Liver Qi stagnation, warm the Yang Qi and nourish the Blood.
Tao Hong Si Wu Wan (consisting of Si Wu Tang plus Tao Ren and Hong Hua) is useful in tonifying and invigorating Blood and regulates menstruation (Bensky, 1990, p. 250). It is particularly effective where Blood deficiency and Stagnation of Blood coexist and lead to clots. When used together with Xiao Yao San these two formulae resolve Liver Qi & Blood stagnation and promote the circulation of Qi and Blood.
Similarly, Shao Fu Zhu Yu Tang and Xiao Yao San promote the circulation of Blood and Qi, warm the menses and alleviate pain (Bensky, 1990, p. 316). I used Shao Fu in the early stages when the blood clots were between 10-20¢ pieces in size. Once the size of the clots had reduced to both fewer in number and smaller in size, I used Tao Hong Si Wu Wan.
Once there were no longer any clots, Tao Hong Si Wu Wan and Xiao Yao San were used during the period to make sure the endometrium was completely cleared from the uterus.
Ba Zhen Tang and Ba Ji Yin Yang Wan were used together in the final stages of Pam’s treatment to nourish the Blood and fill the Chong channel following her period up to ovulation. Post ovulation, I used You Gui Wan with Ba Zhen Tang.
Other Treatment Suggestions
1. Increase hydrating fluid intake to approximately 2 litres per day, as Pam was not drinking enough water (less than a litre per day).
2. An extensive dietary assessment was made and it was recommended she eat less processed foods and use fruits and vegetables that were in season. It was suggested to use seasonal vegetables in soups or steamed as the major part of the meal together with some good quality lean meat and/or fish.
3. Daily intake of 400mcg of folic acid to prevent the possibility of spina bifida in the foetus (De Wals, et al., 2008; Oakley Jr, 2009).
Ongoing Treatment of Patient
Progress:
After 1 month (June ’03):
No headache since last treatment (One week ago, was only mild)
No dizziness
No tinnitus
No blurring of vision
Sleeps well, Not Dreaming as vividly
Libido is not too bad (improving)
Tongue: Thin white coating with strawberry spots
After 2 months (July ’03):
Headaches have reduced dramatically in both frequency and severity, but do still occur
No more dizziness or tinnitus
No more blurred vision
Sleep has improved – still has some vivid dreams, but much less often.
Libido has improved further, but could still be better
PMT:
Tender breast (not as bad as in the past)
Mood swings (still quite bad)
Still gets quite irritable
Some twinges in lower abdomen
Period:
Started on Day 29 (day 1)
Few Clots 10¢ in size
Scant to start with, normal flow for about 2-3 days then peters out
Duration 5 days
Tongue: Normal colour with thin white coating
Pulse: Sl. rapid and slippery
After 4 months Sep. ‘03
PMS:
Virtually no symptoms, with the exception of a slight tenderness in the breasts (90% better then at start of treatment).
No mood swings and no irritability
Period:
27-day cycle
Intermittent flow, no pain, and no clots
Duration 6 days
Other s+s:
Feels good and has more energy.
Good level of libido
No headaches for over 6 weeks
Tongue: Sl. Red, no coating
Late October ‘03
Period overdue – feels as if she might be pregnant.
No PMT symptoms at all
Feels great
Has an increased appetite
Pulse: sl. slippery
Tongue: sl. red body, very thin coating
Tx: at this time Ba Zhen Tang was used exclusively until pregnancy was confirmed.
NB: Pregnancy confirmed in early November 2003
Prognosis and Treatment Response
The treatment goal was achieved after 7 months and the patient gave birth to a healthy baby boy 9 months later.
Integration between TCM and Western Medicine
Infertility is good example of how TCM and WM can be combined to safely and effectively treat infertility, even though in this particular situation this was not the case. On her website, Jane Lyttleton (2010) lists several studies that show the successful combination of TCM and WM in treating infertility: www.acupunctureivf.com.au/pages/research_and_reviews.php and how Acupuncture can increase the success rate achieved with IVF.
Concluding Remarks
This case study demonstrates the importance of considering all of the patient’s pathologies as a whole, rather than simply focusing on infertility, which would be, and indeed was, the approach used by WM. The stagnation of both Qi and Xue needed to be resolved in order for pregnancy to be possible. This is evident by the failed use of fertility drugs before TCM treatment was implemented. Pam was treated throughout her pregnancy and there were very few issues that developed. She had no morning sickness or any other medical issues and ultimately had an uncomplicated birth. Had the Liver Qi stagnation remained unresolved there would have been issues with morning sickness and probably several other health issues during her pregnancy. It is therefore the author’s opinion that despite the strong desire of couples to have a baby and the urgency ascribed to it, it is imperative that all underlying health issues are resolved as much as possible before the woman becomes pregnant.
References
Annon. (2010). Infertility (Lecture to TCM Masters Students ed.). Milperra: UWS.
Bensky, D., Barolet, R. (1990). Chinese Herbal Medicine: Formulas & Strategies. Seattle, Wasington: Eastland Press, Inc.
De Wals, P., Tairou, F., Van Allen, M. I., Lowry, R. B., Evans, J. A., Van Den Hof, M. C., et al. (2008). Spina bifida before and after folic acid fortification in Canada. Birth Defects Research Part A - Clinical and Molecular Teratology, 82(9), 622-626.
Lim, D. (2010). PCOS. UWS Milperra Campus.
Lyttleton, J. (2004). Treatment of Infertility with Chinese Medicine. Edinburgh: Churchill Livingstone.
Lyttleton, J. (2010). Research and Reviews. 2010, from http://www.acupunctureivf.com.au/pages/research_and_reviews.php
Maciocia, G. (1998). Obstetircs and Gynecology in Chinese Medicine. Edinburgh: Elsevier Churchill Livingstone.
Oakley Jr, G. P. (2009). The Scientific Basis for Eliminating Folic Acid-Preventable Spina Bifida: A Modern Miracle from Epidemiology. Annals of Epidemiology, 19(4), 226-230.
Rebar, R. W. (2008). Infertility. from http://www.merck.com/mmpe/sec18/ch256/ch256a.html?qt=Infertility&alt=sh
Zhou, J., & Qu, F. (2009). Treating gynaecological disorders with traditional Chinese medicine: A review. African Journal of Traditional, Complementary and Alternative Medicines, 6(4), 494-517.
