JCM Review
"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.
Peter Deadman
