The cycles of fertilization, budding, maturing and bearing fruit are at the root of all natural cycles, especially the cycles of life and death. The Chinese philosophy of yin/yang, which encompasses the evolution of inward/outward, passivity/movement, Light/dark, form/function, enhances our perception of beginning and end and helps us construct a view of nature, which is ever continuing, through all natural stages. This philosophy is the root of Acupuncture.
A woman’s menstrual cycle is one of natures’ examples of the perfection of the idea of a beginning, a developing, and a conclusive/continuing rhythm in nature. It begins a cycle as it concludes another, ends a cycle while another one begins.
This understanding of the rhythm of nature makes Chinese Medicine and Acupuncture a great tool for assessment of problems in fertility and for course of treatment.
Chinese medicine and Acupuncture offer a less expensive, less invasive and safer alternative to western treatment and has fewer side effects. Acupuncture treats the whole individual. If conception is not successful with the aid of acupuncture and herbs, a woman’s health will still benefit from the treatment, as it supports the general health, and well being of the patient.
The western definition of infertility is the failure to conceive after one year of regular sex without conception.
According to Chinese medicine, the definition of primary infertility is the failure to conceive after having regular sex without contraception for a period of two years. Secondary infertility refers to this same two- year stipulation, however, it occurs in a woman who has previously been pregnant at least once.
What differentiates Fertility and Infertility?
95% of couples trying to conceive, with normal fecund ability, will conceive within 13 months of regular sexual intercourse. Approximately 10-15% of couples in the US access our health care system for difficulty with infertility. About 40% of these couples have difficulty with the male factors. 10% of these cases are considered idiopathic. The other 50% are cases where the female experiences difficulty conceiving.
6.2 million women in the United States are unable to conceive. This is an increase of 26% more than 10 years ago. In 1995, approximately 2.7 women sought medical help for infertility. This was twice as many as in 1987. 10% are women between the ages of 20-29, 25% are between 30 and 39 and more than 50% are over 40 years of age.
With this rise in the age of the population of women trying to conceive, (which is due to popularity of the birth control pill, women committing to career opportunities, and economic factors effecting the quality of life of Americans) fertility is a challenge.
A differential diagnosis is necessary for accurate measure of the potential of any population assessed for Acupuncture.
With Acupuncture, diagnosis is determined by the pattern or patterns created by the symptoms which are present. The most basic assessment of pattern differentiation is the eight principles. The eight principles refer to eight categories for identifying patterns. These are principles are: yin, yang, cold, hot, internal, external, vacuity and excess. These principles have been used since the time of, The Huang Di Nei Jing, circa 200 BC.
These principles describe the location of the disease (interior or exterior), whether it is hot or cold, vacuous or excess, yin or yang. This helps the practitioner to analyze, diagnose and treat disease more carefully. The practitioner can observe the nature of the disease and better understand how it changes through the interactions of these eight principles.
These patterns can be assessed and successfully treated when working with fertility, with or without Western methods of treatment.
How Chinese Medicine and Acupuncture Work
Climactic patterns, when seen in nature, are produced by hear, wet, cold, wind, damp and dry. Various stages of movement contribute to these patterns; there is dry heat in the desert, an abundance of wind in a tornado, stagnation of humidity in a bayou.
The same balances, imbalances, variations and extremes, create the patterns in Chinese medicine and are regulated with Acupuncture.
When observing patterns in fertility, one would note the patient’s constitution, their age at menarche, the nature of their menses, any vaginal discharge, dietary issues, urine, stool, thirst, tongue or pulse. All these symptoms create patterns which discern pathology and create a treatment plan.
For example, if there is heat, you may see, a red tongue, a fast or wiry and slippery pulse, early periods with a thick and dark colored flow, physical heat, sweating a preference for cold fluids, bound stools or deep yellow urine, which is short and maybe painful.
Cold symptoms are tight, slow pulse, pale tongue, painful and late menses, clear or white vaginal discharge, a feeling of cold or desire for warm drinks and copious, clear urination.
In vacuity pattern, there may be signs, such as, late menarche, delayed or irregular menses, little blood, a weak, fine pulse, and little discharge.
In a repletion pattern, one may see dark color of the menses; there may be clots, low abdominal pain that is worse with pressure, dark tongue with macules and a wiry pulse.
Most problems with fertility are patterns connected with imbalances in aspects of the digestion, constitution, and the uterus. The qi and blood, being aspects of energy and fluids, also create complications with fertility.
Yin and yang are balancing opposites in the way of the Tao. Basically, yin reflects fluids, cold, internal signs and the yang reflects excess, heat, external signs.
How Chinese Medicine works with Fertility: Defining terms
To analyze the patterns most frequently applied to problems found with fertility, one needs an understanding of the mechanisms of action involved. This creates the differential diagnosis.
In Chinese Medicine, conception relies on the Ministerial Fire, the essence, the kidneys, the blood, the liver, the qi, the Chong and the Ren to form a new being. It also relies on the Po or spirit in the breath of the mother.
These terms are defined by the culmination of research materials used for this paper.
There are 2 aspects of the Kidneys, which are essential for fertility. They are part of the Jing or essence, which has a yin aspect and a yang aspect.
The part of the essence, which we inherit from our parents, the pre-natal qi, is the yang aspect and is called the Ministerial Fire. This is the ability to ‘spark’ conception. The other part is the acquired essence, which comes from the food and nutrition we take in and is transformed by the spleen and stomach. This is the substance of the yin aspect.
For conception to occur, these yin and yang aspects need to balance. The yin essence needs to nourish and support the egg, and the yang aspect activates the cycle where fertilization occurs. The Ministerial Fire’ evaporates’ and transforms the substance of the yin essence. The water produced by this evaporation’ forms menstrual blood. This is how blood vacuity is an aspect of kidney yang vacuity.
The kidney is considered the ‘congenital foundation’ of the body.
Kidney yin is the ground for the yin of the whole body, all the organs and viscera. It nourishes and moistens the body. Kidney yang warms and aids in the function of the organs and tissues of the body. Yin and yang are each responsible for the 2 major phases of the menstrual cycle.
Woman are prone to blood vacuity because of the loss of blood with the monthly menses. Blood is a major nourishing and yin substance in the body. It si managed by the heart, stored by the liver and made by the spleen. The ministerial fire evaporates yin essence and the water produced by this evaporation forms menstrual blood. The liver stores the blood and regulate s the ‘Chong” vessel, which is an extra meridian pathway governing the uterus and the menstrual flow. The spleen regulates the blood and transforms the qi into blood. Poor diet and stress contribute to blood vacuity.
Since blood is the substance of the menses, any disharmony in its flow creates a disturbance in the menstrual cycle and difficulties with fertility. Vacuity of blood can lead to stagnation of blood so that it is not filling or nourishing the uterus.
The uterus is called the Mansion of Blood. It is one of six extra organs, which means it is yang in shape (hollow) and has a yin function of nourishing the fetus and storing blood. The uterus is related to the kidneys from the Uterus channel (Bao Luo), related to the heart via the Uterus Vessel (Bao mai). And receives blood from the liver. Fertility and menses need heart blood, liver blood and kidney essence to descent to the uterus.
The uterus needs to be warm to function well. Cold in the uterus stagnates and contracts, impairing the circulation of qi and blood. This affects the opening and closing or receptive quality of the uterus. Cold can come from an external invasion or by kidney yang deficiency.
In Chinese Medicine, the Uterus includes the ovaries and the fallopian tubes.
Qi is the “fundamental substance constituting the universe and all phenomena were produced by the changes and movement of qi”. There are a few different types of qi, which I won’t discuss here. What is applicable here, are the functions of qi. It moves, warms, holds, defends and transforms all aspects of bodily activity. There is no place it does not permeate the spleen makes qi from the food and nutrition we take in. THE spleen uses qi to make blood. In this way, the spleen is responsible for deficiency of qi and of blood. Because of the interaction of the liver and the spleen, where the liver can control the transportation and transformation functions of the spleen, the liver stagnates qi. When qi stagnates, it prevents the spleen from healthy functioning and causes blood deficiency.
The liver is responsible for the smooth flow of qi and so, the smooth flow of blood. Especially during menstruation. (Qi is the commander of blood. Blood is the mother of qi). It also is connected to the Uterus, in storing blood for the menses. If there is stagnation, there will be blood stasis and painful menses and masses accumulate. This is why liver qi stagnation can play an important part in fertility problems.
Dampness is a pathogen, which occurs when the spleen qi is vacuous and its function of transportation and transformation are weakened. When this occurs, the yin substance of food and nutrient, which should be transformed, accumulates and create dampness. Damp is characterized by heaviness, turbidity, stagnation and stickiness, which stubbornly obstructs and impairs the circulation of qi and blood. Dampness primarily settles in the lower jiao or lower part of the body where it can create abdominal masses.
THE EXTRAORDINARY VESSELS
The extraordinary vessels are channels, which combine points from the twelve primary channels, which regulate qi and blood through the body. They are especially useful in gynecological problems as they have a close relationship with the kidney, uterus and the liver.
Both Eastern and Western medicine agree that, the first aspect that needs to be dealt with, when dealing with infertility, is the regulation of the menstrual cycle. The following is a synopsis of each of these approaches.
Infertility: The Western Perspective
Infertility, viewed by Eastern or Western standards, is based on the rhythm of the menstrual calendar.
To start with the Western model, the cycle begins with the beginning of menstruation. This is day one. The menses is a discharge comprised of 25-65 ml of blood, mucus, tissue fluid and epithelial cells. Western medicine believes a cycle should start every 21-36 days and last 3-7 days. At the beginning of menstruation, estrogen and progesterone levels are at they’re lowest. This creates vaso-constriction of spiral arterioles leading to ischemia, which leads to the degenerating of the strata functionalis and the rupture of spiral arterioles inside the uterus. Patchy areas of the stratum functionalis detach, shed and pass out of the body along with uterine gland discharges and tissue fluids.
This same decline in estrogen and progesterone results in release of GnRH (gonadotropin releasing hormone) from the hypothalamus, which results in release of FSH (follicles secreting hormone) from the pituitary.
FSH acts on the ovaries, where it allows 20-25 primary follicles (ocyte), (200,000 of which are in the ovary since birth.) to begin to mature and form secondary follicles. Toward the 4th or 5th day of the menstrual cycle, they begin producing low levels of estrogen. When the stratum functionalis is shed, all you have left is the stratum basalis and so the endometrium is thin. Estrogen stimulates the repair of the endometrium. The stratum basalis cells undergo mitosis and a new stratum functionalis develops. It usually thickens to the size of 4-6 mm.
Primary follicles develop into secondary or growing follicles consisting of a secondary oocyte and many layers of cells, forming from a layer of epithelial cells around a primary follicle. The epithelial cells develop into cuboidal cells and then columnar cells called secondary follicles.
This leads to the next phase of the cycle called the pre-ovulation phase or the follicular phase lasting 6-14 days.
All secondary follicles don’t mature at the same rate. The most mature secondary follicles create graulosa cells, which release more estrogen. This secondary follicle is a vesicular or graafian follicle. It continues to grow and develop a clear glycoprotein layer (between the secondary oocyte and the granular cell) and to secrete follicular fluid that pushes the secondary oocyte to the edge of the secondary follicle and fill the follicular cavity. This creates a bulge on the edge of the ovary. As it matures, it continues to increase estrogen production.
Besides cooling and moistening the cervix, estrogen also creates a negative feedback on the FSH. The decrease in FSH creates atresia of all immature secondary follicles.
High levels of estrogen act on the hypothalamus to increase secretion of GnRH or Gonadotropin Regulating hormone which stimulates the anterior pituitary gland to release Leutinizing Hormone (LH).
This surge in LH is responsible for the rupture of the graafian follicle and release of the secondary oocyte into the pelvic cavity. At this time, the follicle has completed the reduction division stage of meiosis and is going into metaphase of equatorial division or meiosis II. The ovum is discharged, from the follicle and is carried by peritoneal serous fluid, into the uterine tube.
This is the end of the follicular phase.
The leuteal phase begins after ovulation. LH stimulates the graafian follicle left behind by the mature ovum, to collapse around the clot of fluids. This becomes the corpus luteum, which secretes estrogen and progesterone. Progesterone is necessary to prepare the endometruim for the fertilized egg. This preparation occurs in the week following ovulation. It involves, secretory activity of the endometrial glands, vascularizing the superficial endometrium, and thickening it. Progesterone is warming and so its abundance results in dryness of the cervix and warming of the body temperature causing the cells of the uterus to swell and store glucogen and tissue fluid.
Progesterone is the dominant hormone during this part of the cycle.
If there is no fertilization, the corpus luteum degenerates, production of estrogen and progesterone decreases, the corpus luteum becomes the corpus albicans and another menstrual cycle begins.
At the same time, the decrease in estrogen and progesterone effect the anterior pituitary, which releases FSH as the hypothalamus releases GnRh and another ovarian cycle starts.
Ideally, the follicular, or pre-ovulatory phase, should be 14 days long. The leuteal phase should be another 14 days.
Pharaceuticals are the Western standard for treating infertility. There are treatments for various stages and fertility problems. The following are the utilized drugs and tests available.
Clomid (Clomiphene Citrate) stimulates ovulation in women who are not ovulating by stimulating the development of the egg in the ovaries. It can cause the second phase of the cycle to be abnormally short and prevent the egg from being able to implant in the uterus. There may be a risk of ovarian cancer for women taking this drug and it dries cervical fluid. Ovulation is successful in about 75% of the women treated with Clomid, but subsequent pregnancy is 30-40%.
Pergonal is a stronger drug, also used to stimulate ovulation. It is pure FSH and often releases more than one egg at a time. It is the drug given to women who are conceiving through IVF (In-vitro Fertilization).
Repronex is an extract from the urine of post-menopausal women. It is used for its FSH and LH gonadotropin activities. It produces follicular growth and maturation. When enough maturation occurs. HCG is given to induce ovulation.
Fertinex is given with HCG, sequentially, to stimulate the development of multiple follicles in patients undergoing IVF.
Gonad –F is another drug for inducing ovulation. Pregnancy rates achieved after use are 58-82% and side effects are multiple pregnancies and ovarian hyper-stimulation.
Lupron prevents LH from surging prematurely. This prevents endometrial hyperplasia and endometriosis. Long-term side effects are hot flushes, bone demineralization and atrophic vaginitis.
HCG is Human chorionic gonadotropic. It is an injectable method of inducing ovulation. It is the hormone tested in pregnancy tests.
Artificial insemination is a Western aid for fertilization. It is used, primarily, when a man’s sperm count is low, a woman’s cerival fluid is not considered fertile enough and when infertility is unexplained.
IVF or in-vitro fertilization is the most widely accepted method of conception with Western aids. The eggs are removed from the female and fertilized with the sperm in a Petri dish, then placed back in the uterus after 48 hours. Couples use IVF when they are unable to conceive naturally. The challenge is in implanting the fertilized egg and the woman’s body accepting it.
GIFT is Gamete Intra-fallopian Transfer. This differs from IVF because the gamete is placed in the woman’s fallopian tube instead of a Petri dish. This helps with her body’s acceptance of the gamete. This is also a more expensive and invasive procedure and is two to three times more successful than IVF.
ZIFT is Zygot Intra-fallopian Transfer. In this procedure, the egg and sperm are fertilized in a Petri dish and placed in the fallopian tubes. This procedure is used when the quality of the man’s sperm is marginal.
Western science has developed tests to determine the health of a woman’s fertility. Ovulation predictor kits test urine for LH, there are home pregnancy tests for HCG,
Serum progesterone is tested to note if ovulation occurred, hormone blood tests detect FSH, LH, estrogen and progesterone and the health of ovaries. HSG or Hysterosalpingogram detect if fallopian tubes are open and laparoscopy is exploratory surgery used to view the ovaries and fallopian tubes and to detect endometriosis. When there are congenital problems, which are not evident, chromosome analysis can be performed.
Basal Body temperature or BBT is a method of registering the temperature changes, which occur during the various aspects of the menstrual cycle. The temperature is taken every morning when a woman wakes up, before she gets out of bed, or moves around. A BBT thermometer measures body temperature by 1 tenth of a degree, therefore it is able to measure the subtleties of temperature shifts which are due to hormone regulation. 14 days after the cycle begins, which is, ideally, when ovulation should occur, there should be a temperature increase of 4-6 degrees F. This is due to the increase of progesterone. The 24 hours following this rise in temperature is the time immediately after ovulation when a woman is most fertile. During menstruation, the temperature normally drops .6 degrees. In this way, the cycle can be monitored.
Fertility: The Eastern Perspective
In the eastern medicine model, the BBT chart is measuring the ministerial fire, which is the basic essence or ‘spark’ of life, which is yang and yin. The yang aspect, which is the spark of life, is the thermal quality of progesterone, as it activates the warming aspect of the cycle, preparing the endometrium for fertilization. The yin aspect is the oocyte, which goes through the steps of meiosis as a gratin follicle and the fluids created before it splits off as an ovum.
The time of ovulation is the transfer of yin becoming yang. The time of menstruation is the time of yang converting to yin. The follicular phase is the yin aspect of the cycle and the leuteal phase, that yang aspect.
As yin and yang are interdependent, it is important to keep a balanced support of each during the cycle, with an emphasis on whichever aspect is prominent during each phase.
The menstrual cycle begins on the day the menses starts. This is day one. At this time, liver qi and blood should flow freely. The liver moves the qi and stores the blood and thus provides blood for the uterus at the time of menses. When there is deficiency of blood, qi stagnates, as blood nourishes qi. When there is qi stagnation, blood movement is impaired. Liver qi stagnation causes most of the discomfort of PMS symptoms. In this case, the liver is not smoothly moving the blood.
At this time, it is also important to nourish the yin, as yin is starting to grow. This is the time when the body is replenishing itself and yin is moistening and softening the cervix. A practitioner can start to nourish the yin at about day 3, which is 3 days after the first day of menses.
TCM believes the cycle should be 26-32 days long and the menses should last 4-6 days.
It is important to note that, through any part of the menstrual cycle, it is important to nourish the heart and liver as, in TCM, they manage and store the blood, respectively. It is also important to move blood if it is scanty and to stop bleeding if heavy. At around day 7, after the menses starts, blood and yin, the ren and the Chong are depleted and need to be nourished.
Many fertility problems relate to anovulation. Promoting ovulation is treated at around day 10 of the cycle. This is done by activating the circulation of qi and blood and promoting the transformation of yin to yang. At this time, the blood and yin fill the Ren and Chong. Nourishing the liver blood and kidney yin and essence are important. Strong yang tonics are added at this time, to strengthen the force of yin in reaching a focused peak, which is needed in order to ovulate.
During this yin part of the cycle, which is considered the first 14 days and the days between menstruating and ovulating, there may be a tendency to see damp obstruction (an accumulation of yin substance) leading to infertility problems. Spleen qi vacuity, which can lead to damp accumulation and damp accumulation, may be dealt with here.
Liver qi or heart qi stagnation can also be seen at this time because yin is nourishment and substance, yang is movement. There can also be bleeding at this time, caused by yin deficiency and hyperactivity of the liver, which could both create heat and bleeding.
The heart function is an important element at the time of ovulation. According to Oriental medicine, the heart rules the blood vessels and the ‘filling’ and ‘emptying’ of the uterus, are an aspect of this.
Along with the heart, it is important to harmonize the function between the heart and the kidney, as the uterus, is the vessel between the heart and the kidney. When there is poor ovarian and pituitary function, there is usually a disturbance in the heart. If there is an excess of heat at this time, which one can see in the BBT, there will be disharmony between the heart and kidney, disturbing the function of yin and blood, before ovulation and weaken the yang aspect of growth in the post-ovulatory phase.
Premenstruation, or the follicular phase, begins with ovulation and ends with menstruation. It is the second phase of the menstrual cycle and usually lasts 14 days. It is dependent on yang and qi to raise the level of progesterone and warm the uterus. At this time, qi and blood should be strong, as the qi, which is associated with yang, is warming and necessary to move the blood, which is building. This is important for keeping yang strong and warming. If a patient is supplemented, at this time, one must be careful not to warm too much, and create an imbalance of heat or fire. Qi stagnation is more likely to occur at this time, and so it is important to keep the system moving, while not moving it too much.
During menstruation, the heart and kidneys need to be harmonized because of their relationship with the uterus. At this time, there may be a marked deficiency in blood, in which case the spleen would need to be nourished.
This is a general view of the female reproductive cycle and its related aspects, both eastern and western. There are other complications, which may occur. Blocked fallopian tubes relate to damp heat, and may involve blood stasis and fire toxins, ovulation irregularities relate to the kidneys, uterine myomas to blood stasis with possible phlegm. Pelvic adhesions relate to damp-heat with blood stasis.
In summary, it is not possible to make a direct correlation between Eastern and Western terms. The stages of the menstrual cycle relate on the level of activity and substance. This chart is a summary of the comparisons between these terms:
|Menses||Yang becoming yin|
|Post menses||Blood vacuity|
|Follicular Phase||Yin phase|
|Estrogen cools and moistens||Yin substance|
|FSH acts on ovaries to form follicle||Follicle is yin substance|
|Ovulation||Yin becomes yang|
|Increase of GnRH stimulates LH||Ministerial fire boosts yang|
|Surge of LH||Boost of yang|
|Progesterone warms and dries cervix||Yang|
|Cells of uterus swell and store glycogen and tissue fluid||Yang becomes yin|
|Menses||Yang becomes yin|