For those of us who focus our clinical work on treating patients with infertility, the publication 10 years ago of the first edition of Treatment of Infertility with Chinese Medicine was something of a light in the darkness. The information was good, the diagnostic systems worked, the formulas were effective (Gui Shao Di Huang Tang - we salute you), and patients - more often than not - were happy (and pregnant). The author introduces this second edition of Treatment of Infertility with Chinese Medicine by pointing out that the 10 years since the first edition represent ‘a long time in a rapidly developing field like [Western] reproductive medicine … but a very short time in Chinese medicine’. These 10 years have seen Chinese medicine (and particularly acupuncture) for infertility become big business in the West. This started in 1992 when Wolfgang Paulus and his colleagues published research showing the positive benefits of acupuncture for patients undergoing IVF. Within a short time the resulting demand from a smart, well-informed and moneyed patient-base meant that every acupuncturist suddenly became a fertility ‘specialist’ (or else risked losing patients to the next practitioner who was happy to fit this role). This decade has even seen the emergence of Chinese medicine ‘brand names’ trying to corner the infertility market. There has also been much more information published on the subject, and practitioners have by necessity had to become ever more knowledgeable about how to effectively treat in this area. So although Chinese medicine itself may not have changed much, the Western consumer landscape in which it operates has transformed significantly. Given these seismic changes, and given my own part in the flourishing Chinese medicine fertility ‘market’, I was looking forward to this second edition of Jane Lyttleton’s book.
Lyttleton has clearly immersed herself in her chosen field whilst continuing to learn from her Chinese medicine teachers, the emerging new technologies and her patients. Her writing is clear, economical (thankfully not overly technical) and is replete with clinically relevant information. The most valuable aspect of this text is the authorial voice - a voice characterised not only by experience and knowledge, but also by sharing similar challenges, concerns and questions as her readers. For example, when describing the dilemma faced by the practitioner when treating threatened miscarriage caused by blood stasis; rather than just listing the relevant herbs / acupuncture points as many texts would, the author acknowledges the significant risks of moving blood during early pregnancy, and shares her extensive knowledge of the subject (such as that Wu Ling Zhi and Pu Huang have been found to be very safe in Chinese clinics when treating such cases). Clinically speaking, Lyttleton has clearly ‘been there and done that’ - and where she has identified problems she has made it her business to find out and think the problem through. Readers of this text benefit from this hard-earned wisdom.
The text is generally well – if slightly sporadically - referenced (occasionally medical ‘facts’ are trotted out without evidence), but there is much to learn here. For example, practitioners of Chinese medicine are frequently critical of the effects of the contraceptive pill on the female reproductive cycle – stagnating the qi and blood, but how many of us communicate to our patients the studies that show that of women who conceive after the age of 35, those who have taken the pill for eight years or more have half the miscarriage rate (due to the resulting conservation of their eggs)? How many of us are aware that in cases of threatened miscarriage caused by blood deficiency Dan Shen can be used in the formula, despite its blood moving properties, and has in fact been shown in Chinese studies to rectify retarded foetal growth? The book is full of this type of clinically pertinent information.
The clinical approach presented in the text is reassuringly familiar, without being simplistic. Based on classical formulas with simple modifications it is accessible and practical. There is also plenty in here to keep acupuncturists happy – the acupuncture and herbs are reasonably well balanced, and most of the plentiful case studies use both. That the treatment presented in the case studies corresponds reasonably closely to the theory presented in the text was welcome, and equally refreshingly – if sadly - not all of the cases described have a happy ending; babies are lost, lessons are learned.
The relevant biomedically-defined diseases (endometriosis, PCOS etc) are systematically described according to current biomedical knowledge before the requisite Chinese medicine theory is presented. The new sections on immune infertility and recurrent miscarriage were the main draw for me, as there has been precious little clinically robust information published in these areas. These cases frequently involve women who seem to be in excellent health and have the best in terms of biomedical support, but who are still unable to get – and stay - pregnant. While this text is far from the last word on these subjects (and it would be churlish to criticise this, given that even biomedicine is in its infancy in this regard) Lyttleton presents a robust clinical approach to these problems that both stimulated and tallied with my own thinking about the subject. I was also keenly anticipating the new section on PCOS – an impressively detailed presentation that takes diagnosis and treatment of the disease far beyond the glib ‘Kidney yang deficiency with phlegm’ that often constitutes the TCM gloss on this disease. Add to this a substantial new section on treating alongside IVF, and an extensive new section on lifestyle and fertility that summarises the apparently infinite number of ways that the modern world adversely effects human fertility, and this text definitely constitutes a ‘2.0’ improvement on the last model.
With all of these excellent aspects I was puzzled why pole position in the book was given to a mildly patronising foreword from a Sydney IVF consultant, who between the lines seems to suggest that Chinese medicine treatment is a kind of elaborate hand-holding for psychologically delicate patients. The same old clichés are trotted out, and the familiar power structures are tiresomely present (‘This book is an immense achievement because not only does it give an excellent account of TCM, but it does it in the context of Western anatomy and physiology…’). Fortunately Steven Clavey is on hand in his foreword to concisely affirm one of the most pertinent points: ‘The key to the popularity of Chinese medicine is its effectiveness’. While there are of course potential problems with the integration of Chinese and Western medicine, Lyttleton toggles between the two effortlessly, and the clarity and neat structure afforded by TCM suits the necessities of her clinical approach perfectly. Whilst classical fundamentalists may squirm in their silk pyjamas, such integration can be both intriguingly creative and edifying (‘By Day 9, the number of blood vessels in the dominant follicle is twice that of other follicles. It is this … which dictates the use of Blood-building and Blood-regulating medicinals at this time.’). Such integration can also clear up some thorny issues in clinical practice – take for instance the frequent absence of typical signs and symptoms of blood stasis in patients with recurrent miscarriage due to thrombophilias, which for Lyttleton is explained by the fact that when blood stasis is ‘at this level of microcirculation we may not see a lot of obvious clinical symptoms of blood stasis’.
My main bugbear with the first edition of this text was that although the book worked well as a narrative - reading from beginning to end - it was problematic as a reference book. The information was there, but it was often hard to find. Unfortunately this is still largely the case. Throughout the text the key clinical information - theory, guiding formulas and acupuncture points – tends to be presented as punctuation of a narrative of the female menstrual cycle. Granted, the organisation of such a body of knowledge is extremely challenging: not only are there the various Western disease labels, their associated Chinese medicine patterns and all the associated modifications of acupuncture/herbal treatment, there are the different stages of the menstrual cycle to contend with. And there is an upside to this approach in that it is apparently based on a commitment to presenting the material as it is used in clinic: no simplistic correspondence of one formula per pattern here. Rather, Lyttleton’s treatment is applied according to the constantly changing requirements of women’s menstrual rhythms.
If you are an acupuncturist or herbalist working with patients with infertility, you should own a copy this book. Both as a primer/reminder of the biomedical aspects of infertility, and as a clinical manual presenting an effective approach to TCM treatment, it is a sound and durable investment. Anyone new to the subject will study this text for years and still come back for more, whilst those who already own the first edition will find enough new material to warrant updating their existing (presumably dog-eared) copy.
Review of first edition by Peter Deadman
"The practice of Chinese medicine is maturing in the West", says Steve Clavey in the introduction to Jane Lyttleton's longawaited book on infertility. In just 25 years it has moved into mainstream Western culture, is increasingly taught at university level and is practised by tens of thousands of practitioners who have an increasingly sophisticated grasp of its theory and application. What has been rare until now, however, is to find Western practitioners who have worked deeply within one area of specialisation and can offer the fruits of this clinical expertise to fellow practitioners. Specialisation, as Clavey points out, has been an integral part of the practice of Chinese medicine for 700 years, since the imperial court of the Song dynasty established separate departments of medicine. To master a speciality requires long study and clinical observation, followed by extensive and attentive practice. This in itself is quite rare, but to benefit other practitioners also requires the ability to write well, to order information logically, and to have a clear grasp of what needs to be explained and how to do so in such a way that it is understood, and this is also rare. The combination of these two essential requirements is what makes this such an exceptional book – one of the finest ever published in English in the field of Chinese medicine. Indeed, the fluency of the writing, attention to detail, anticipation of questions that might be asked by other practitioners and students, and the willingness to clearly summarise clinical experience – all requirements for the Western reader - mean that this book could probably only have been written by a Westerner. This is indeed a true sign of the maturity of the profession. The first great strength of this book is its happy, almost seamless, integration of Western and Chinese medicine. However enamoured of Chinese medicine a practitioner might be, it is impossible to treat infertility - and engage in informed discussions with patients and their gynaecologists - without a good grasp of Western medicine, especially when dealing with the complexities of assisted reproduction technology. And gynaecology – infertility in particular – demonstrates one of the most successful marriages of biomedical and traditional Chinese medicine, much of it developed by Chinese doctors and most especially by Dr. Xia Gui Cheng, the director of the Gynaecology department in a large TCM hospital in Nanjing. He is well known for his expertise in the treatment of infertility and his pioneering work with using basal body temperature (BBT) charts as part of his TCM diagnosis. As far as the Western medicine approach to infertility is concerned therefore, this is a wonderful resource, since its explanations are lucid, and above all the author knows what the intended readership (mostly TCM practitioners but also other interested health professionals) really needs to know. This distinguishes it from any other biomedical gynaecology book that I have seen in the many years I have studied the subject. The first chapters on the menstrual cycle and the BBT exemplify the approach of this book. On the one hand, the TCM understanding of the cycle is wonderfully explained, whether clarifying the relationship between the Heart and the uterus and their interconnection via the Bao Mai, or the role of jing-essence (and how to diagnose jing deficiency in women and understand its aetiology), or the interplay of yin and yang through the different phases of the cycle. On the other hand, the biomedical description of the cycle is given in great detail, and the two approaches are related in an entirely practical way. Thus a whole variety of different patterns that may be seen in the BBT chart (the practical aspects of getting patients to record them are fully explained) are correlated with TCM patterns, for example long, short, high or unstable, follicular phases; short, low or unstable luteal phases etc. When it comes to diagnosis and treatment of female infertility, the key aspects of ovulation and menstruation and the questions to ask concerning them are emphasised, and the bald and often unhelpful pattern differentiations for infertility found in many TCM textbooks are fleshed out with essential guidelines. For example, although four patterns (Kidney deficiency, Heart and Liver qi stagnation, blood stagnation and phlegm-damp accumulation) are normally given, the author emphasises that in practice Kidney deficiency is addressed – at least in part – in most infertility patients, and offers her own more clinically useful approach to pattern differentiation; for example that problems related to ovulation or the first part of the menstrual cycle are most commonly related to Kidney yin deficiency and second most commonly to Heart qi stagnation, with both of these potentially complicated by Liver qi stagnation, phlegm-damp or blood stasis. In terms of treatment, regulating the different patterns of disharmony whilst at the same time modifying the treatment according to the phase of the cycle is unavoidably quite complex. Typically of this book, the treatment – by herbs and acupuncture – is methodically explained. Core proven prescriptions are given, with appropriate modifications, and the acupuncture points are both straightforward and well explained. Many case histories are scattered through the book, illustrating aspects of the treatment and diagnosis. Substantial chapters are devoted to gynaecological disorders which can cause infertility, and their treatment (endometriosis, amenorrhoea, pelvic inflammatory disease etc.), and fallopian tube blockage is comprehensively covered. The information here is invaluable; for example, the prognosis for TCM treatment of fallopian tube blockage – which kinds are likely to be amenable to treatment and which are not. Women with fallopian tube blockage, like many infertile women, are often desperate for accurate information, especially when considering undertaking what is likely to be a difficult, lengthy and expensive treatment that may involve many months of herbal decoctions. The more informed the prognosis, the better the outcome is likely to be for both practitioner and patient. In up to 50% of couple infertility, the male partner is at least partially responsible, so treating male subfertility or infertility may be essential. Male infertility responds well to Chinese medical treatment, is relatively simple to treat and is well covered in this book. Further chapters cover miscarriage (its prevention, treatment when threatened, and treatment of sequelae), ectopic pregnancy, and diet and lifestyle in relation to infertility. The final chapter, 'Assisted Reproduction Technology and TCM', is alone worth buying this book for. It thoroughly explains the different protocols and explains how and in what circumstances Chinese medicine treatment can be either helpful or contraindicated. This is an especially hot topic, with recent research showing that adding acupuncture to the treatment protocol of IVF patients increases their chances of becoming pregnant by nearly 50%. A fair reviewer tries to find something to criticise in the midst of such unstinting praise, although it is hard to do in this case. Perhaps in a future edition, the pinyin names could be given whenever acupuncture points are mentioned (in many cases they are), and although this book marks a significant improvement in Churchill Livingstone's notoriously bad design and layout, it is occasionally difficult to navigate through subsections. Jane Lyttleton emphasises that the treatment of infertility can be difficult. Many patients cannot be helped, and many find that improvements in their menstrual cycle and general health and wellbeing, do not lead to the yearned for result of pregnancy. The patient-practitioner relationship can also be both demanding and intensely intimate. Nevertheless, there are few satisfactions in medicine greater than assisting a woman in becoming pregnant. To offer the very best treatment for infertility requires sound and deep knowledge, which until now has been extremely difficult to obtain. Jane Lyttleton has performed a great service to practitioners worldwide – and to their patients – in authoring this wonderful book.