Female Infertility & Reproductive Gynaecology: A Comprehensive Clinical Manual of Integrated Chinese Medicine and Biomedicine
This landmark manual is the most complete presentation of the integrated Chinese and biomedical treatment of infertility and reproductive gynaecology in the English language. Although primarily devoted to Chinese herbal medicine, the comprehensive discussions of every aspect of infertility, and the acupuncture protocols given for every pattern, will benefit every practitioner working in the field.
Its primary author, Professor Yuning Wu, is principal doctor and Professor of Integrated Chinese and Western Medicine at the Beijing Hospital of Traditional Chinese Medicine and is one of the most eminent fertility specialists working in China. Infertility is one of the fields where the finest integration of the two medicines can be found and Yuning Wu demonstrates throughout this deeply clinical book the strengths of this dual approach. However, her deep knowledge of biomedicine and her willingness to use it whenever appropriate should not obscure her mastery of Chinese medicine. Readers will quickly discover that her disease diagnosis, pattern differentiation, choice of prescriptions, precise modifications and understanding of individual medicinal substances is of the highest order and based on extensive clinical experience. Chinese medicine practitioners throughout the world and their many thousands of grateful patients owe her an enormous debt for making the fruits of a lifetime of dedicated medical practice so generously available to all.
As she writes in the Preface, “In this book, I offer my nearly 50 years of experience without holding anything back in order to help practitioners truly understand the essence of Chinese medicine. This includes understanding the aetiology of disease by differentiation of its symptoms and signs (审证求因, shen zheng qiu yin), individualised treatment based on pattern differentiation (辨证论治，bian zheng lun zhi), and the concept of holism (整体观念, zheng ti guan nian) which always considers the patient as a whole and strives to regulate the balance of yin and yang, qi, blood and the zangfu organs to treat disease and prevent relapse. I also emphasise tongue inspection as the most important of the four diagnostic methods. It is essential to prescribe flexibly based on each herb’s properties and flavours, its channels entered and its ascending or descending movement. Different prescriptions have to be given according to the stages of the cycle, always paying attention to protecting yin and blood since women lose blood and Kidney yin throughout their life. Chinese medicine disease diagnosis and pattern differentiation should be combined with biomedical diagnosis whenever appropriate in order to improve therapeutic results. This is an entirely practical clinical manual. I hope that it serves as a valuable teacher and companion for readers to treat menstrual disorders and infertility with Chinese medicine alone or in combination with biomedicine. I sincerely hope it brings benefit to the people of the world.”
Female Infertility & Reproductive Gynaecology: A Comprehensive Clinical Manual of Integrated Chinese Medicine and Biomedicine
by Yuning Wu and Celine Leonard with Michael Haeberle, case history contributions by Esther Denz
When I was asked to review Female Infertility & Reproductive Gynaecology: A Comprehensive Clinical Manual of Integrated Chinese Medicine and Biomedicine, my initial thought was ‘Finally, someone wrote the book!’ Over my 25 years of practice and teaching, I have frequently been asked by students for a complete reference text for herbalists treating infertility. It has arrived. Yuning Wu, Celine Leonard and Michael Haeberle have produced a definitive source for practitioners that clearly outlines how we should think about diagnosing and treating the complicated clinical presentations that manifest in women struggling with infertility.
A five-year, nearly 500-page editing project by the authors and the editorial team of Peter Deadman, Inga Heese and Daniel Maxwell, I found this book completely accessible yet with meticulous detail and depth. Organised similarly to my own lineage in traditional Chinese medicine and consistent with my teaching and practice, in Part One the text outlines disorders of menstruation - where all gynaecology begins. Regulate the cycle first, and you are well on the way to a successful outcome. Principal Doctor and Professor of Integrated Chinese and Western Medicine at the Beijing Hospital of Traditional Chinese Medicine, fertility expert Yuning Wu thoroughly presents the basic theory and fundamental strategies of diagnosis and treatment. Once disorders of timing, bleeding and pain have been addressed, the integrated assessment and treatment of biomedically defined diseases are outlined in Part Two of the text, starting with those most commonly seen in the infertile woman such as polycystic ovarian syndrome, myoma or endometriosis. I was delighted to see extensive discussion on complex disorders associated with infertility and miscarriage such as immune disorders, as well as early pregnancy care. Each disease includes comprehensive discourse by Dr Michael Haeberle, a reproductive endocrinologist based in Zurich, Switzerland, detailing the biomedical understanding, evaluation and standard treatment of each condition.
My appreciation of the clarity of the presentations on syndrome differentiation cannot be overemphasized. Dr. Wu takes the reader through the basic patterns, discusses the most commonly used herbal formulas and highlights appropriate modifications, all with a precise and logical progression from diagnosis to treatment principles to herbal formula, with respectful homage paid to the source text of each prescription. A wonderful detail is the listing of the individual herbal properties for each modification, such as ‘add pungent-sweet-warm Ba Ji Tian (Morindae officinalis Radix) 10g for Kidney Yang deficient lower back pain’. Each chapter includes helpful clinical notes emphasising strategies to use or avoid, such as employing caution when prescribing blood-invigorating herbs in the luteal phase, or avoiding the herb Bu Gu Zhi(Psoraleae Fructus) when a woman is actively trying to conceive. Illustrative case studies from the clinics of Dr Wu, Celine Leonard and Esther Denz accompany every chapter, providing important real-world examples of the presented theory. Although this is primarily a herbal text, acupuncture strategies are also included with each chapter, with guidance not only regarding point selection and timing, but also technique and adjunct techniques such as moxa.
What is truly unique about this text is how well it weaves Chinese medicine and biomedical evaluation and treatment strategies. When an infertility patient presents to the clinic, she may be either brand new to, or very familiar with the language of Chinese Medicine. Unexperienced patients here in the West typically discuss their presentation using biomedical terms, so it is incumbent on the practitioner to be familiar with the terminology and assessments of biomedicine and assisted reproduction techniques (ART). New patients may not be familiar with what a ‘normal’ menstrual cycle should be like, nor have the necessary terminology to discuss it. My initial evaluations of fertility patients typically include education and self-care techniques including basal body temperature (BBT) tracking and fertility awareness, descriptions of which are also included in the text for each disease presentation. These can be useful adjunct tools to help patients feel more proactive in their care and see objective progress.
Patients who are further along in the fertility journey may present with a long history of ART interventions and effectively become involuntary experts in their own reproductive health. Practitioners in possession of only a cursory understanding of biomedical diagnoses, presentations and treatments will not instill confidence in such patients. An experienced patient will discuss lab results, interventions and medication usage that have effects with which the practitioner should be familiar. Even though Chinese medicine physicians diagnose using our own tools, it is important to know how to work with this information, particularly when making appropriate referrals and setting treatment expectations. For example, having integrated knowledge of a disease like endometriosis is essential for a few reasons. First, the diagnosis can be casually used by patients based on a history of dysmenorrhoea, dyspareunia or infertility; they may be unaware that this disease can only be officially diagnosed via laparoscopy. If they have not had any direct medical imaging, but there is a strong suspicion, a referral is indicated and such intervention will likely delay attempts to conceive. Additionally, treatment of complex diseases such as endometriosis will often require several months of treatment to address the presenting patterns; in the case of blood stasis this will involve herbs that the patient is specifically advised to avoid during conception. Most women desiring pregnancy do not want to delay, but informing them that treatment requires temporarily postponing their attempts is usually met with agreement if presented with a well-informed approach. Dr Wu discusses no less than five main patterns for treatment of endometriosis with Chinese herbal medicine, with five associated formulas, but also dozens of modifications for patients with different types of pain, bleeding and other systemic symptoms, along with commentary on dosage and the specific substances she most often uses clinically. The formulas are presented according to timing - whether to be taken before, during or after period - in order to optimise treatment success, and the chapter includes not only internal herbs, but external herbal compresses and retention enemas as additional treatment options. She then outlines how to progress from active treatment of the disease to directly promoting fertility once symptoms have been alleviated. This is but one example of how Dr Wu uses Chinese medicine specifically to fit the individual, not the disease, whilst understanding the complexity of treating such a serious obstacle to fertility.
Another complicated disease seen frequently among women with infertility, polycystic ovarian syndrome (PCOS), has diverse clinical presentations, and in Chinese medicine terms there are many atypical presentations beyond the classic ‘Kidney yang deficiency with phlegm-damp’ presented in many texts. Some women are unaware that they have PCOS and they may not have had an evaluation with a gynaecologist prior to visiting the Chinese medicine clinic, so being able to recognise the possible patterns will help in terms of making appropriate informed referrals, as combining Chinese medicine with orthodox medication is sometimes necessary. Here again, Dr Wu outlines the Chinese medicine presentations followed by thorough biomedical definitions and evaluations by Dr Haeberle. Common treatments for both are detailed, along with prognosis and expectations for each of these methods. The details of each pattern and sub-pattern are discussed with great attention to detail and nuance - so refreshingly different from the simple protocol-based approaches that are often given. Dr. Wu’s huge clinical experience also means that she can provide important cautions that emphasise the limitations of both systems of medicine, as well as when to refer or combine the two medical approaches.
Biomedical treatments for infertility evolve so rapidly that it is challenging - but important - to stay current with the ever changing approaches. The understanding of what has been previously been inexplicable changes, such as in the common presentation of ‘unexplained infertility’. Patients with this diagnosis are often frustrated, as they have nothing specifically identified they might do in order to ‘fix’ their problem. Chinese medicine can be very successful with these patients; it may be simply a matter of adjusting relatively subtle imbalances, an area where herbal medicine excels. Dr Wu also presents lesser discussed biomedical conditions such as luteinised unruptured follicle syndrome (LUFS), which is common in patients diagnosed with unexplained fertility and according to the text may occur in up to 23 per cent of otherwise normal menstrual cycles. This condition where the follicle does not rupture is not well understood yet is believed to be more common in infertile women even than endometriosis or pelvic inflammatory disease (PID). As with other syndromes, Dr. Wu details how this can be evaluated and differentiated using Chinese medicine and BBT, and discusses how to fine tune treatment to promote successful ovulation without the unwanted and potentially dangerous side effects of hormone treatment such as hyperstimulation, which is seen more often in women with LUFS and PCOS.
This text includes ome very complicated and difficult-to-treat conditions such as hyperprolactinaemia, diminished ovarian reserve, premature ovarian failure and tubal infertility that are rarely discussed in any detail in the extant literature. Comprehensive explanations, prognoses and references provide realistic and well informed options for care for these poorly understood and often left-as-untreatable pathologies. The authors discuss when is appropriate to consider hormone treatment or surgery as well as when patients are likely to not be successful in their attempts to conceive naturally.
This text goes beyond getting pregnant and there are comprehensive chapters on staying pregnant – and how to treat patients with recurrent miscarriage or a history of ectopic pregnancy. These conditions can be life threatening if not treated properly. While extensively knowledgeable about factors that contribute to these pathologies, such as sexually transmitted and pelvic infections, Dr. Wu remains firmly grounded in evaluating and treating according to Chinese medicine pattern differentiation in each and every case. Whilst she understands the biochemical actions of Chinese herbs according to pharmacological research, these findings remain merely secondary to her traditional approach.
Later chapters discuss in great detail how to integrate treatment for patients undergoing intra uterine insemination (IUI) and in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI). Dr. Wu describes six stages of treatment to accompany orthodox treatment, which are adapted to match the orthodox treatment used before, during and after egg maturation and retrieval. She specifies how and when to warm, move or tonify and which herbs to use and avoid. This is the most detail I have ever seen in a Chinese medicine text, and is designed and discussed with great clarity and specificity. Also included is a chapter on ovarian hyperstimulation syndrome (OHSS), which whilst not common, can be very dangerous. Being able to identify patients at risk for OHSS and recognise a patient who may be experiencing this during an IVF cycle can literally save a life. As Chinese medicine practitioners, we are more likely to be helpful in the recovery phases of OHSS as is outlined in the text.
The text closes with a chapter on caring for women during early pregnancy, and includes specific herbal and acupuncture cautions during pregnancy that should always be respected. Appendices that follow include endangered species and contraindicated herbs, glossary of medical terms and abbreviations, blood test values, classic acupuncture prescriptions for fertility and methods of dispensing Chinese herbs.
As a long-time practitioner and teacher of Chinese medicine with extensive experience in the treatment of female infertility, I am delighted to finally see a comprehensive integrated reference text that practitioners can use to advance their knowledge and treatment options. According to the Centers for Disease Control and Prevention, about 1 in 10 women in the United States aged 15–44 have difficulty becoming or staying pregnant. This population deserves well informed, skilled practitioners of Chinese medicine as well as biomedicine. This book represents an excellent source text for integrating these two medical systems. I look forward to recommending it to colleagues and students.
Foreword by Peter Deadman xvii
Preface by Professor Yuning Wu xviii
Preface by Celine Leonard xx
Chapter One: How to use this book 1
Chapter Two: Basic theories of Chinese medicine gynaecology and infertility 3
Chapter Three: Core strategies for treating female infertility 7
Part One: Disorders of menstruation
Chapter Four: Regulating the period using Tiao Jing Fang (Regulate the Menses Formula) 25
Chapter Five: Disorders of timing - short cycles 29
Chapter Six: Disorders of timing - long cycles 41
Chapter Seven: Disorders of timing - irregular cycles 57
Chapter Eight: Disorders of bleeding - menorrhagia 67
Chapter Nine: Disorders of bleeding - scanty menstruation 79
Chapter Ten: Disorders of bleeding - prolonged menstruation 91
Chapter Eleven: Disorders of bleeding - midcycle bleeding 101
Chapter Twelve: Disorders of bleeding - abnormal uterine bleeding (beng lou) 115
Chapter Thirteen: Miscellaneous disorders - dysmenorrhoea 133
Chapter Fourteen: Miscellaneous disorders - premenstrual syndrome 149
Part Two: Gynaecology and infertility
Chapter Fifteen: Amenorrhoea and anorexia nervosa 167
Chapter Sixteen: Polycystic ovary syndrome 197
Chapter Seventeen: Myoma (fibroids) 217
Chapter Eighteen: Ovarian cysts 233
Chapter Nineteen: Endometriosis and adenomyosis 249
Chapter Twenty: Luteal phase defect 281
Chapter Twenty-One: Luteinised unruptured follicle syndrome 295
Chapter Twenty-Two: Hyperprolactinaemia 311
Chapter Twenty-Three: Tubal infertility 323
Chapter Twenty-Four: Diminished ovarian reserve and premature ovarian failure 339
Chapter Twenty-Five: Recurrent miscarriage 357
Chapter Twenty-Six: Immune infertility and immune recurrent miscarriage 373
Chapter Twenty-Seven: Using Chinese medicine to support assisted reproductive technology treatment 407
Chapter Twenty-Eight: Ovarian hyper-stimulation syndrome 437
Chapter Twenty-Nine: Pregnancy care 453
Appendix 1: Animal and endangered products and herb cautions 463
Appendix 2: Dispensing Chinese herbal medicines 466
Appendix 3: Basic fertility and pregnancy blood test values (with US/European conversions) 467
and explanation of abbreviations Appendix 4: Classical acupuncture prescriptions for gynaecology and infertility 469
Chapter 1: How to use this book
Chapter 2: Basic theories of Chinese medicine gynaecology and infertility
3 The fundamental importance of the Kidney in reproductive life
3 The other zangfu
3 Yin yang theory and the menstrual cycle The four stages of the menstrual cycle
4 Stage 1: Purging of blood through the period, days 1-5 (maximum 7 days)
4 Stage 2: Postmenstrual growth of blood and yin (follicular phase), days 6-13
4 Stage 3: Ovulation, days 14-15
4 Stage 4: Premenstrual, luteal phase, days 16-28
5 Notes on using the BBT to refine diagnosis and treatment
5 Common disharmonies of the reproductive system
6 Fundamental treatment strategies with Chinese medicine
CHAPTER 3: Core strategies for treating female infertility
7 Aetiology and pathogenesis
8 Kidney yang deficiency
10 Kidney yin deficiency
12 Liver qi stagnation
13 Stagnation of phlegm-damp
14 Blood stasis
14 Blood stasis due to cold
16 Blood stasis with heat
17 Clinical notes
17 History and physical examination
17 Ovulatory assessment
18 Menstrual history and BBT
18 Urinary luteinising hormone
18 Transvaginal ultrasonography
18 Other evaluations
18 Ovarian reserve
19 Cervical factors
19 Uterine abnormalities
19 Tubal potency
20 Peritoneal factors
Part One: Disorders of Menstruation
Chapter 4: Regulating the period using Tiao Jing Fang (Regulate the Menses Formula)
25 Clinical notes
26 Tiao Jing Fang (Regulate the Menses Formula)
26 Scanty bleeding
26 Heavy bleeding
CHAPTER 5: Short cycles
29 Aetiology and pathogenesis
30 General treatment strategy
30 Deficiency of Spleen qi
31 Kidney deficiency
32 Empty heat from Kidney yin deficiency
34 Full heat
35 Clinical notes
35 Modifications for patients wishing to conceive
36 Case study from the clinic of Dr. Yuning Wu: Short cycle with scanty menstruation and secondary infertility
39 Case study from the clinic of Celine Leonard: Short cycle with dysmenorrhoea and lower abdominal pain
Chapter 6: Long cycles
41 Aetiology and pathogenesis
42 General treatment strategy
42 Blood deficiency
43 Kidney deficiency
45 Stagnation of qi and blood
46 Stagnation of phlegm-damp
47 Blood obstructed by cold
49 Case study from the clinic of Dr. Yuning Wu: Long cycle and scanty bleeding
51 Case study from the clinic of Celine Leonard: Long cycle and infertility
54 Case study from the clinic of Esther Denz: Long cycle, unexplained female infertility and PMS
Chapter 7: Irregular cycles
57 Aetiology and pathogenesis
58 General treatment strategy
58 Kidney deficiency
59 Liver qi stagnation
61 Kidney deficiency with Liver qi stagnation
62 Case study from the clinic of Dr. Yuning Wu: Irregular cycle with PCOS and infertility
Chapter 8: Menorrhagia
67 Aetiology and pathogenesis
67 Deficiency of qi
69 Blood heat
71 Blood stasis
72 Clinical notes
72 Case study from the clinic of Dr. Yuning Wu: Menorrhagia and infertility
75 Case study from the clinic of Celine Leonard: Menorrhagia and myoma
Chapter 9: Scanty bleeding
79 Aetiology and pathogenesis
80 Blood deficiency
81 Kidney deficiency
82 Blood stasis
84 Stagnation of phlegm-damp
86 Clinical notes
86 Case study from the clinic of Dr. Yuning Wu: Scanty periods and infertility
88 Case study from the clinic of Dr. Yuning Wu: Scanty periods and infertility
Chapter 10: Prolonged periods
91 General treatment strategy
92 Aetiology and pathogenesis
92 Deficiency of qi
93 Empty heat from Kidney yin deficiency
96 Blood stasis
97 Case study from the clinic of Celine Leonard: Prolonged menstruation and adenomyosis
Chapter 11: Midcycle bleeding
101 Aetiology and pathogenesis
101 Differentiation of patterns
102 Kidney yin deficiency with empty heat
104 Blood stasis
105 Clinical notes
106 Case study from the clinic of Dr. Yuning Wu: Midcycle bleeding and scanty menstruation
108 Case study from the clinic of Celine Leonard: Midcycle bleeding and infertility
111 Case study from the clinic of Celine Leonard: Midcycle bleeding and dysmenorrhoea
Chapter 12: Abnormal uterine bleeding (beng lou)
115 Aetiology and pathogenesis
116 General treatment strategies
116 Kidney yin deficiency with empty heat
117 Kidney qi deficiency
119 Spleen qi deficiency
120 Blood heat
121 Blood stasis
123 Clinical notes
123 Women of reproductive age
124 Case study from the clinic of Dr. Yuning Wu: Abnormal uterine bleeding and irregular periods
126 Case study from the clinic of Dr. Yuning Wu: PCOS, abnormal uterine bleeding (beng lou) and infertility
Chapter 13: Dysmenorrhoea
133 Aetiology and pathogenesis
134 Differentiating menstrual pain: overview, timing, quality, location of pain
135 Stagnation of qi and stasis of blood 136 Excess cold leading to blood stasis 138 Damp-heat blocking the lower jiao
139 Deficiency of qi and blood
140 Deficiency of the Kidney and Liver 142 Clinical notes
142 Modified Tiao Jing Fang (Regulate the Menses Formula)
143 Case study from the clinic of Celine Leonard: Dysmenorrhoea and infertility
Chapter 14: Premenstrual Syndrome
Premenstrual emotional symptoms
149 Aetiology and pathogenesis of premenstrual emotional symptoms
150 Premenstrual emotional symptoms due to Heart blood deficiency
151 Premenstrual emotional symptoms due to stagnation of Liver qi/Liver fire
152 Premenstrual emotional symptoms due to phlegm-fire disturbing the mind
Headaches associated with the menstrual cycle
Part Two: Gynaecology and infertility
Chapter 15: Amenorrhoea, Anorexia nervosa
167 Aetiology and pathogenesis 168 Kidney yang deficiency
169 Kidney yin deficiency
171 Deficiency of qi and blood
172 Stomach dryness due to yin deficiency
173 Stagnation of qi and blood
175 Accumulation of phlegm-damp 176 Clinical notes
176 Causes of amenorrhoea
177 Anatomical defects
177 Evaluation of the patient
177 Physical examination
177 Blood tests, normal values
177 High FSH, low AMH
177 Elevated prolactin levels
178 Normal or low FSH levels
178 Hypothalamic amenorrhoea (anorexia nervosa)
178 Adrenal hyperplasia
178 Case study from the clinic of Dr. Yuning Wu: Amenorrhoea and primary infertility
181 Case study from the clinic of Dr. Yuning Wu: Amenorrhoea and polycystic ovary syndrome
183 Case study from the clinic of Celine Leonard: Amenorrhoea
185 Case study from the clinic of Celine Leonard: Amenorrhoea and infertility Anorexia nervosa
187 Aetiology and pathogenesis
187 Deficiency of Spleen qi and Heart blood
189 Stagnation of Liver qi and deficiency of Spleen qi 190 Liver qi stagnation with accumulation of phlegm
191 Clinical notes
192 Case history from the clinic of Esther Denz: Amenorrhoea, anorexia nervosa and infertility
194 Case study from the clinic of Esther Denz: Anorexia nervosa and infertility
Chapter 16: Polycystic ovary syndrome (PCOS)
197 Aetiology and pathogenesis
198 Kidney deficiency with stagnation of phlegm-damp 201 Kidney deficiency with blood stasis
203 Stagnation of phlegm-damp
205 Liver qi stagnation with phlegm-fire 207 Clinical notes
207 Combining Chinese medicine and biomedicine
209 Fertility treatment
209 Case study from the clinic of Dr. Yuning Wu: PCOS and infertility
211 Case study from the clinic of Esther Denz: PCOS with irregular and long cycles and infertility
213 Case study from the clinic of Esther Denz: PCOS with amenorrhoea
Chapter 17: Myoma
217 General treatment strategy 218 Aetiology and pathogenesis 218 Stagnation of qi and blood
220 Stagnation of phlegm and blood 222 Accumulation of damp-heat
223 Clinical notes
225 External treatments
225 Infertility Treatment
226 Surgical treatment of myomas 226 Prognosis
227 Case study from the clinic of Dr. Yuning Wu: Myoma and infertility
Chapter 18: Ovarian cysts
233 Aetiology and pathogenesis
234 Type 1: uncomplicated or simple cysts
234 Spleen qi deficiency with stagnation of phlegm-damp
Ovarian cysts continued/uncomplicated or simple cysts
235 Accumulation of phlegm and blood stasis
237 Damp-heat mixed with blood stasis
239 Type 2: echoic cysts containing solid matter
239 Stagnation of qi and blood
241 Accumulation of phlegm-damp and blood stasis
242 Damp-heat mixed with blood stasis 244 External treatment for ovarian cysts 244 Lifestyle advice
245 Functional cysts
245 Pathological or ‘inclusion’ cysts 245 Epidemiology
245 Types of ovarian cysts 245 Clinical symptoms
246 Caution: ovarian cancer
246 Case study from the clinic of Dr. Yuning Wu: Ovarian cyst and infertility
Chapter 19: Endometriosis and adenomyosis
250 Aetiology and pathogenesis
251 Stagnation of qi and blood 253 Blood stasis due to cold 255 Blood stasis due to heat
257 Combined stagnation of phlegm and blood 258 Blood stasis due to qi deficiency
260 Kidney deficiency and blood stasis 262 Treating during the period
263 Promoting fertility
264 Clinical notes
265 External treatments for endometriosis and adenomyosis
266 Aetiology and pathogenesis
266 Retrograde menstruation
267 Immunologic factors 267 Pathology
267 Clinical presentation
267 Pelvic pain
267 Other symptoms 267 Diagnosis
268 Medical treatment
268 Surgical treatment - laparoscopy
268 Other surgery for endometriosis associated pelvic pain
269 Surgery for the management of infertility
269 Ovarian stimulation and IVF in endometriosis related infertility
269 Integrating Chinese medicine and biomedicine Adenomyosis
269 Symptoms and prevalence 270 Diagnosis
270 Case study from the clinic of Dr. Yuning Wu: Endometriosis and infertility
272 Case study from the clinic of Dr. Yuning Wu: Adenomyosis, adenomyoma and infertility
275 Case study from the clinic of Esther Denz: Endometriosis with dysmenorrhoea and heavy bleeding
Chapter 20: Luteal phase defect
282 Aetiology and pathogenesis 282 Kidney yang deficiency
284 Kidney yin deficiency
286 Kidney deficiency with Liver qi stagnation 287 Clinical notes
288 Prevalence and incidence 288 The corpus luteum
289 Poor follicle production
289 Corpus luteum failure
289 Poor endometrial response
289 Other causes 289 Diagnosis
289 Endometrial biopsy
289 Serum progesterone levels
289 BBT chart 290 Treatment
290 Progesterone supplementation
290 Onset and duration of treatment with progesterone
290 Ovulation induction for inadequate folliculogenesis
290 Monitoring treatment effect
291 Case study from the clinic of Dr. Yuning Wu: Luteal phase defect and recurrent spontaneous miscarriage
Chapter 21: Luteinised unruptured follicle syndrome
295 BBT chart
296 Aetiology and pathogenesis
296 Kidney deficiency with blood stasis
298 Liver qi stagnation with Kidney deficiency 300 Deficiency of the Liver and Kidney
302 Damp-heat with blood stasis
304 Clinical notes
305 Aetiology and pathogenesis
306 Case study from the clinic of Dr. Yuning Wu: LUFS, PCOS and hyperprolactinaemia
Chapter 22: Hyperprolactinaemia
311 Aetiology and pathogenesis
312 Liver qi stagnation with Liver fire
313 Stagnation of phlegm and blood stasis
315 Kidney yin deficiency with Liver yang rising 316 Deficiency of qi and blood
317 Clinical notes
318 Incidence and causes
319 Other causes of hyperprolactinaemia 319 Evaluation of the patient
319 Blood test
319 CT or MRI scan 319 Treatment
320 Case study from the clinic of Dr. Yuning Wu: Hyperprolactinaemia
Chapter 23: Tubal infertility
323 Aetiology and pathogenesis 324 General treatment strategy
325 Stagnation of qi and blood
327 Blood stasis combined with phlegm-damp 328 Blood stasis and fire toxin
330 External treatment
330 Herbal enemas
331 Herbal compresses
332 Causes of tubal infertility
332 Infections and pelvic inflammatory disease (PID)
332 Other causes 332 Diagnosis
333 Complete blockage of the fallopian tubes at one or more points
333 Adhesions/scarring causing partial blockage
333 Complete damage of the tubal mucosa and muscular wall (pansalpingopathy) 333 Treatment
333 Combination of IVF and microsurgery
333 Other considerations
333 Case study from the clinic of Dr. Yuning Wu: Tubal infertility
Chapter 24: Diminished ovarian reserve (DOR) and premature ovarian failure (POF)
339 Aetiology and pathogenesis
340 Kidney yang deficiency with blood stasis
342 Kidney yin deficiency and empty heat with blood stasis 342 Qi and blood deficiency with blood stasis
346 Clinical notes
347 Prognosis Biomedicine 349 Incidence
347 Aetiology and pathogenesis
349 Environmental factors
349 Genetic causes
349 Diagnosis and assessment of POF 349 Reversible POF
350 Treatment of infertility in POF
350 Case study from the clinic of Dr. Yuning Wu: Premature ovarian failure 353 Case study from the clinic of Dr. Yuning Wu: Premature ovarian failure 353 Case study from the clinic of Dr. Yuning Wu: Premature ovarian failure
Chapter 25: Recurrent miscarriage
358 Aetiology and pathogenesis 358 Deficiency of Kidney qi
360 Deficiency of qi and blood
361 Empty heat due to yin deficiency
362 Blood stasis blocking the uterine collaterals 365 Clinical notes
365 Genetics and age
366 Hormonal and metabolic factors 366 Infections
366 Uterine anomalies
367 Inherited thrombophilias
367 Male factors
367 Lifestyle, environmental and occupational factors
367 Antiphospholipid syndrome and other autoimmune and alloimmune factors 367 Case study from the clinic of Dr Yuning Wu: Recurrent miscarriage
Chapter 26: Immune infertility and immune recurrent miscarriage
374 Aetiology and pathogenesis
374 Kidney yin deficiency with empty heat
377 Kidney and Spleen yang deficiency with damp and blood stasis 378 Accumulation of damp heat and toxins
380 Clinical notes
381 Lifestyle advice Immune-related miscarriage 381 Autoimmunity
382 Aetiology and pathogenesis 383 General treatment strategy
383 Kidney deficiency with blood stasis
385 Qi and blood deficiency with blood stasis 387 Toxic heat and blood stasis
389 Clinical notes
390 Aetiology and pathogenesis 391 Kidney and Spleen deficiency
392 Kidney and Liver yin deficiency with empty heat 394 Patient trials
394 Pharmacological research
395 Anti-sperm antibodies (ASA) 395 Anti-ovarian antibodies (AOA)
395 Beta-cell antibodies (in Diabetes Type I)
396 Anti-thyroid antibodies (ATA) – Hashimoto’s thyroiditis 396 Anti-endometrial antibodies (AEA)
396 Anti-phospholipid antibodies (APA)
396 Clinical criteria
396 Laboratory criteria 394 Alloimmune factors
397 Case study from the clinic of Dr. Yuning Wu: Autoimmune-related recurrent miscarriage
399 Case study from the clinic of Dr. Yuning Wu: Alloimmune-related recurrent miscarriage, blocking antibody defect (BAD)
402 Case study from the clinic of Esther Denz: IVF failure and unexplained infertility, later confirmed autoimmune infertility
Chapter 27: Using Chinese medicine to support assisted reproductive technology treatment
407 How Chinese medicine helps patients undergoing ART 408 General treatment strategy
408 Supporting IUI cycles with Chinese medicine
408 Natural IUI cycles
409 Medicated IUI procedures
409 Clomiphene citrate IUI cycles
410 Aromatase inhibitor IUI cycles
410 HMG/FSH with IUI
411 Supporting IVF/ICSI cycles with Chinese medicine
411 The six stages of treatment to accompany IVF/ICSI
411 Adapting treatment to match the IVF protocol
410 Preparation: Regulating (tiao)
410 Down-regulation: Nourishing (bu)
414 Menstruation: Purging (tong)
415 Stimulation: Promoting (cu)
416 Egg collection: Relaxing (song)
417 Consolidating: Astringing (gu)
417 When ART cycles fail: guidelines for treatment
419 Repeated failed cycles
419 Treatment of ‘poor responders’
420 Treatment for patients who produce many poor quality eggs
420 Treatment for a thin endometrium
421 Treat the Kidney
421 Treat post-natal qi
421 Treat blood stasis
421 Drugs for ovulation induction
421 Clomiphene citrate
422 Aromatase inhibitors
423 Intrauterine insemination (IUI) 424 IVF/ICSI treatment
424 Long agonist (down regulation)
424 Short agonist (down regulation, flare protocol)
424 Ultra-long agonist (down regulation for patients with endometriosis/adenomyosis)
425 Response prediction
425 Luteal phase support
425 Side-effects of ART treatment 425 Chromosomal screening
425 Patients with advanced reproductive age 425 Poor responders
426 Severe male infertility
426 Case study from the clinic of Dr. Yuning Wu: Repeated IVF failure, PCOS, PMS, OHSS
428 Case study from the clinic of Dr. Yuning Wu: Repeated implantation failure (RIF) and diminished ovarian reserve (DOR)
430 Case study from the clinic of Dr. Yuning Wu: IVF failure, thin endometrium
431 Case study from the clinic of Dr. Yuning Wu: IVF failure, advanced age, diminished ovarian reserve
CHAPTER 28: Ovarian hyper-stimulation syndrome (OHSS)
437 Aetiology and pathogenesis
439 Deficiency of Kidney and Spleen yang with retention of fluid 440 Liver qi stagnation with blood stasis and retention of fluid
442 Kidney and Liver yin deficiency with damp-heat and blood stasis 440 Clinical notes
445 Risk factors
445 Clinical features
446 Case study from the clinic of Dr. Yuning Wu: OHSS, ovarian cyst, PCOS and infertility
CHAPTER 29: Pregnancy care
453 Clinical guidelines
454 Aetiology and pathogenesis
454 Kidney and Spleen yang deficiency 456 Deficiency of Kidney and Liver yin
457 Acupuncture for nausea and vomiting of pregnancy 458 Myoma in pregnancy
458 General advice to patients in pregnancy 459 Guidance for using herbs in pregnancy
459 Herbs forbidden in pregnancy
460 Herbs used with caution during pregnancy
460 Herbs which are contraindicated when trying to conceive or in early pregnancy 456 Assessing research
461 How to deal with the contraindicated herbs 461 Clinical conclusions
|Professor Yuning Wu
|Journal of Chinese Medicine
Tubal infertility is a common condition found in 11 to 15 per cent of infertile couples in Western countries and 49 per cent in Africa.1 Damage to the fallopian tubes is most frequently secondary to genital infections such as chlamydia, mycoplasma or gonorrhoea which can lead to sexually transmitted and pelvic inflammatory diseases (STD/PID). Other causes include endometriosis, prior abdominal or pelvic surgery, appendiceal rupture, ectopic pregnancy, infection from tuberculosis or tubal sterilisation. Diagnosis is not straightforward, however, and confirmation of the exact location and extent of tubal damage often requires a combination of hysterosalpingography (HSG), hysterosalpingo- contrast-sonography, hysteroscopy and laparoscopy with chromopertubation (where dye is passed through the tubes).
There are different degrees of tubal obstruction. Total blockage of the fallopian tubes is not common and is mainly seen following infections or tubal sterilisation. In such cases both tubes are generally affected. Fluid obstruction (hydrosalpinx) can also cause total blockage of one or both tubes as well as lowering conception or implantation rates in IVF, since the fluid contained within the fallopian tubes may flow back to the uterus, preventing implantation and/or washing the embryo away. Partial obstruction of the tubes is more commonly seen, mostly due to infection, surgery or endometriosis.
Biomedical treatment for tubal infertility ideally restores natural fertility via microsurgery. In severe cases, however, IVF - sometimes combined with microsurgery (for example if the fallopian tubes need to be clipped or removed) is the only option.
Chinese medicine can be an effective treatment for some cases of tubal obstruction and can also help to reduce the extent of restorative tubal surgery if required. However, careful assessment of pathological findings from a hysterosalpingogram (HSG), hysteroscopy or laparoscopy is essential, as Chinese medicine is not effective in cases where the fallopian tubes have atrophied and/or are so severely damaged that they have become fibrotic. In this case the patient may need to be advised that ART is necessary.
However, for partial tubal blockage or damage to the ciliated mucosa where the transport of the egg is impaired, Chinese medicine treatment can improve the local tubal environment to help transportation of the fertilised egg towards the uterus. If there is a mild hydrosalpinx, it can help to reduce the quantity of fluid obstructing the tube and may avoid the need for microsurgery. In mild cases of hydrosalpinx, Chinese medicine alone can lead to a pregnancy. Successful treatment, however, will generally take at least two to three months.
The patient may present in clinic with an existing diagnosis of tubal infertility and seek treatment to resolve it in order to conceive. Alternatively, she may have been diagnosed with hydrosalpinx and be looking for an alternative to tubal clipping before ART procedures. Treatment will require herbal decoctions or concentrated herbal powders in addition to herbal enemas and/or herbal compresses applied to the abdomen. It will also need to be carried out in conjunction with diagnostic scans to assess the course and effectiveness of treatment. Acupuncture can also be used but must be combined with herbal treatment.
Aetiology and pathogenesis
The diagnosis of tubal infertility is always informed by modern medical diagnostics such as hysterosalpingogram, hysteroscopy and/or laparoscopy. Tubal obstruction in
Chinese medicine is categorised as blockage of the uterine collaterals (bai luo). This blockage is excess in nature, and always involves blood stasis combined with qi stagnation, phlegm-damp or heat.
Liver qi stagnation
Stress, frustration and constrained emotions will impair the patency of Liver qi and give rise to Liver qi stagnation. Qi stagnation then leads to blood stasis and eventually blockage of the fallopian tubes. Alternatively, the function of a weakened Spleen can be further diminished by Liver invasion so that blood deficiency develops. Blood then fails to nourish the Liver, aggravating Liver qi stagnation and leading to blood stasis and tubal blockage.
Stagnation of phlegm-damp
A weakened Spleen, a lack of support from Kidney yang, and/or poor dietary choices or habits can lead to inability of the Spleen to transform and transport fluids and the formation of dampness and phlegm. Phlegm-damp combines with residual blood stasis in the abdomen or obstructs the flow of blood to create blood stasis. The combination of phlegm-damp and blood stasis leads to blockage of the fallopian tubes.
Prolonged stagnation of qi can lead to systemic heat. Alternatively, overconsumption of spicy and fatty foods, alcohol or stimulating drugs can lead to heat in the Stomach which is then transmitted to the blood. Heat condenses the blood and causes blood stasis and blockage of the tubes.
Prolonged dampness can transform into damp-heat, Liver stagnant heat can combine with dampness, or external damp-heat can invade. Damp-heat combines with residual blood stasis post menses, postpartum or after pelvic surgery and together obstruct the flow of blood and give rise to a combination of toxic-heat and blood stasis. This leads to obstruction of the fallopian tubes.
Deficiency of zheng qi
If zheng qi is weakened – which easily happens either post menstrually, postpartum or after pelvic surgery, pathogenic factors such as cold, damp, heat or fire-toxins can invade the uterus and combine with residual local blood stasis to cause obstruction in the uterine collaterals (bao luo). This impairs free movement of qi and blood, obstructs the Chong and Ren mai and prevents conception due to tubal blockage.
Combined emotional and physical trauma such as sexual abuse or assault can lead to stagnation of Liver qi and blood stasis obstructing the channels and vessels of the lower jiao and uterus.
The common factor in all cases of tubal obstruction is blood stasis which combines with other pathogens such as qi stagnation, phlegm-damp, heat or toxic heat to block the bao luo.
General treatment strategy
Moderate cases of tubal obstruction can be treated with herbs that have a mild action of invigorating blood or fluids, such as Hong Hua (Carthami Flos), Yi Mu Cao (Leonuri Herba) and Lu Lu Tong (Liquidambaris Fructus).
More severe obstruction requires the use of herbs with a strong blood invigorating and breaking action, such as Tao Ren (Persicae Semen), San Leng (Sparganii Rhizoma) and E Zhu (Curcumae Rhizoma).
Very severe obstruction may require animal substances with a blood breaking action, such as Tu Bie Chong (Eupolyphaga/Steleophaga) and Shui Zhi (Hirudo seu Whitmaniae).
Strong blood invigorating formulas, however, must always be adapted to the patient’s overall condition. Care is needed so that treatment does not damage the patient’s qi and yin. If the patient has a weak constitution, strong medicinals alone will not produce the required result and qi tonifying herbs are necessary to counterbalance them. As zheng qi increases there will be greater vitality and better micro-circulation of blood.
Patients with partially obstructed tubes who are trying to conceive can still be treated if certain clinical guidelines are followed. For those whose tubes are open but there is still incomplete spillage of fluid during a hysterosalpingogram, treatment can be adapted to combine an oral herbal formula to promote ovulation with a herbal enema for direct treatment of the tubal obstruction (see later in the chapter for details). From the end of the period until just before ovulation, retention enemas can be used to help open the tubes, in addition to any internal formulas the patient may be prescribed. Since, however, the patient is trying to conceive, potentially mild toxic substances such as Tu Bie Chong should be replaced by other strong blood movers such as E Zhu (Curcumae Rhizoma).
Differentiation of patterns
The patterns associated with tubal infertility are all excess in nature.
Stagnation of qi and blood
Blood stasis combined with phlegm-damp Blood stasis and fire-toxin
Stagnation of qi and blood
There is premenstrual breast distention and irritability, possibly with emotional outbursts. The period is painful with dark-purple clotted blood and the cycle can be irregular. The patient complains of frustration, irritability, depression, headaches, distention or oppression of the chest, all of which may worsen from ovulation to the period. There is often a previous diagnosis of pelvic inflammatory disease or endometriosis, with confirmation of tubal blockage.
Tongue: dark with a purple hue and/or dark spots; the coating is thin white, or thin yellow if stagnation has generated heat.
Pulse: thin, wiry or choppy.
Regulate qi and invigorate blood to dispel blood stasis and obstruction in the uterine collaterals.
Modified Hua Yu Tong Luo Fang (化瘀通络方, Prescription to Dispel Blood Stasis and Open the Collaterals, Dr. Wu’s formula)
Dang Gui (Angelicae sinensis Radix) 10g Chuan Xiong (Chuanxiong Rhizoma) 6g Chi Shao (Paeoniae Radix rubra) 10g Tao Ren (Persicae Semen) 10g
San Leng (Sparganii Rhizoma) 10g E Zhu (Curcumae Rhizoma) 6-10g
Tu Bie Chong (Eupolyphaga/Steleophaga) 6-10g* Lu Lu Tong (Liquidambaris Fructus) 10g
Chai Hu (Bupleuri Radix) 6g
Zhi Huang Qi (honey-prepared Astragali Radix) 10-15g
When a condition involves a physical obstruction rather than a functional disturbance, stronger-acting herbs and a greater length of treatment are needed to achieve a successful outcome. However, since strongly moving herbs easily damage the body’s qi, such treatment must involve careful consideration of the underlying constitution and current health of the patient. The prescription recommended here is a modification of the blood nourishing formula Si Wu Tang (Four-Substance Decoction) with the addition of protective qi-tonifying Zhi Huang Qi (honey-prepared Astragali Radix). Nourishing blood will soothe the Liver and help with the qi stagnation that has caused tubal blockage, hence the use of pungent- warm Dang Gui and Chuan Xiong to both nourish and invigorate blood. Pungent-cool Chi Shao replaces Bai Shao for its nourishing, moving and anti-inflammatory action. Neutral Tao Ren, pungent-neutral San Leng and pungent- warm E Zhu break up blood stasis. In order to even more strongly break up blood, salty-cold Tu Bie Chong is added. Bitter-neutral Lu Lu Tong invigorates blood, promotes movement in the channels, induces diuresis and disperses swelling to assist in clearing obstruction, while pungent- cool Chai Hu disperses stagnant qi. Honey fried Huang Qi is added to tonify qi, indirectly helping to spread qi as well as protecting the body from potential damage due to long- term administration of strong blood invigorating herbs.
- If the patient complains of feeling cold and presents with a blueish tongue, warm and pungent substances with a capacity to move through and open the channels should be chosen. Add sweet- pungent-warm Gui Zhi (Cinnamomi Ramulus) 6-10g or pungent-warm Xi Xin (Asari Herba) 1-3g. Gui Zhi will expel cold and warm the blood, while Xi Xin (forbidden in certain countries) is strongly aromatic and spreads stagnant qi. It can move internally into the collaterals and outwardly to the skin, penetrating and opening the orifices. If, however, the patient has a weak thin pulse, tiredness and shortness of breath (indicating more qi deficiency) then add Dang Shen (Codonopsis Radix) 10-15g.
- If there is tiredness but the tongue is purple-red with dark spots and a scanty coating, this indicates that blood stasis has damaged yin, and yin tonics which also tonify qi are added. If there is mild yin deficiency add neutral to mild-cold Yu Zhu (Polygonati odorati Rhizoma) 10-15g. For severe yin deficiency add sweet-mild-cold Bei Sha Shen (Glehniae Radix) 10-15g.
- Blood stasis tends to generate heat. In such cases sweet-warm honey-prepared Huang Qi (Astragali Radix) should be changed to mild-warm unprepared
Sheng Huang Qi. Mild-cold Mu Dan Pi (Moutan Cortex) 6-12g can also be added to assist Chi Shao in cooling and invigorating blood.
- If the period tends to be delayed, blood invigorating herbs with a descending action will help advance it. According to the condition of the patient, add one of the following - neutral Chuan Niu Xi (Cyathulae Radix) 10-20g, mild-cold Yi Mu Cao (Leonuri Herba) 10g or warm Du Zhong (Eucommiae Cortex) 10-15g.
- With a shorter cycle where stagnation of qi has generated heat, careful attention must be given to adapting the formula. It may be necessary to add astringent herbs such as sweet-bitter-cold Sheng Di Huang (Rehmanniae Radix) 6-15g, sweet-cold Di Gu Pi (Lycii Cortex) 6-12g or cool astringent Mu Li (Ostreae Concha) 20-30g (pre-cooked for 20-30 minutes). Blood invigorating herbs such as warm E Zhu and neutral San Leng may need to be replaced by bitter-cold Qian Cao Gen (Radix Rubiae Cordifoliae) 10-15g, sweet-neutral Chao Pu Huang (dry-fried Typhae Pollen) 10g, Pu Huang Tan (carbonised Typhae Pollen) 10g, or sweet-warm powdered San Qi (Notoginseng Radix) 2 x 1.5g/day, taken separately with warm water (if heat is not pronounced), or neutral Ou Jie (Nelumbinis Nodus rhizomatis) 15g to regulate the cycle and invigorate blood.
- Since the formula strongly invigorates blood, it should be stopped three days before the period in order to prevent heavy bleeding, and replaced by Tiao Jing Fang (Regulate the Menses Formula) which should be continued throughout the period to control pain and bleeding and dispel blood stasis (See Chapter 13: Dysmenorrhoea for more details).
Acupuncture treatment is focused on spreading Liver qi and invigorating blood in the lower jiao. In most cases of tubal obstruction, acupuncture alone is unlikely to be sufficient and should be combined with internal as well as external herbal medicine. For patients receiving surgery, acupuncture treatment can be used pre- and post- surgery to regulate qi and blood and thereby assist with conception. Needle technique is by reducing method.
- To spread Liver qi: Taichong LIV-3 combined with Hegu L.I.-4 (the ‘Four Gates’), Yanglingquan GB-34, Zulinqi GB-41, Zhongdu LIV-6, Zhangmen LIV-13, Qimen LIV-14.
- If Liver qi stagnation has given rise to heat: Xingjian LIV-2, Ligou LIV-5, Yangfu GB-38.
- To nourish Liver blood to soothe Liver qi: Sanyinjiao SP-6, Ququan LIV-8, Ganshu BL-18.
- To invigorate blood in the lower jiao: Diji SP-8, Xuehai SP-10, Geshu BL-17, Daimai GB-26, Tianshu ST-25, Shuidao ST-28, Guilai ST-29, Qihai REN-6.
- To activate the Chong mai to regulate blood: Gongsun SP-4 and Neiguan P-6, Qichong ST-30, Siman KID-14, Huangshu KID-16.
Blood stasis combined with phlegm-damp
The patient is overweight and complains of a long cycle with mucus visible in the menstrual blood. There is often excessive sticky-white vaginal discharge. There may be oedema, greasy hair or skin, tiredness and lethargy that is worse on waking or after napping or resting. There is a confirmed diagnosis of tubal obstruction and there may be a concurrent diagnosis of PCOS, pelvic adhesions and/ or hydrosalpinx.
Tongue: pale, dark and swollen with teethmarks and a white greasy coating.
Pulse: slippery or soggy, sometimes choppy.
Drain and dry dampness and transform phlegm, dispel blood stasis and soften hard masses.
Qu Tan Tong Luo Fang (祛痰通络方, Prescription to Transform Phlegm and Move the Collaterals, Dr. Wu’s prescription)
Cang Zhu (Atractylodis Rhizoma) 6-10g Fu Ling (Poria) 10-12g
Zhe Bei Mu (Fritillariae thunbergii Bulbus) 10g Dan Nan Xing (Rhizoma Arisaematis) 6-10g Dang Gui (Angelicae sinensis Radix) 10g
Zao Jiao Ci (Gleditsiae Spina) 10g
Si Gua Luo (Fasciculus Vascularis Luffae) 10g Lu Lu Tong (Liquidambaris Fructus) 10g
Gui Zhi (Cinnamomi Ramulus) 3-10g Tao Ren (Persicae Semen) 10g
This prescription is designed to drain damp, transform phlegm and clear the mass that is blocking the tube. Since physical obstructions always involve blood stasis, it combines herbs to drain and dry damp and transform phlegm with herbs to address the combination of blood and phlegm obstruction. Bitter-pungent-warm Cang Zhu dries damp. Bland-neutral Fu Ling tonifies the Spleen and drains damp. Stubborn phlegm obstruction is addressed by bitter-cool Dan Nan Xing and bitter-cold mass-breaking Zhe Bei Mu. Blood is nourished and invigorated by sweet- pungent-warm Dang Gui. Blood stasis mixed with phlegm is addressed by the piercing action of pungent-warm Zao Jiao Ci and the ability of sweet-neutral Si Gua Luo to open the collaterals and promote movement. This action of opening the collaterals is reinforced by bitter-neutral Lu Lu Tong, which also invigorates blood and drains damp through promoting urination, and by Gui Zhi which invigorates blood and helps the transformation of qi and stagnant fluids. Pungent-neutral Tao Ren both invigorates blood and clears phlegm.
- If the pulse shows deficient Spleen yang and/or there is diarrhoea or feelings of weakness, add bitter-warm Bai Zhu (Atractylodis macrocephalae Rhizoma) 6-15g to strengthen the Spleen and dry phlegm-damp, and Dang Shen (Codonopsis Radix) 10-15g to further strengthen the Spleen qi and assist with transformation of fluids.
- If there is puffiness of the face or under the eyes, swelling of the hands and legs and/or scantier dark urine, change Fu Ling to Fu Ling Pi (Poria Cutis) 15-20g and add Ze Xie (Alismatis Rhizoma) 6-10g or Zhu Ling (Polyporos) 10g.
- If ultrasound or HSG (hysterosalpingography) indicate hydrosalpinx, herbs which simultaneously invigorate blood and drain damp can be used. Pungent-mild-cold Yi Mu Cao (Leonuri Herba) 10g invigorates blood and has a diuretic action. Bitter-pungent-warm Ze Lan (Herba Lycopi Lucidi) 10g also invigorates blood and drains damp, while Che Qian Zi (Plantaginis Semen) 10-15g promotes diuresis and transforms and drains phlegm-damp.
- If the HSG, pelvic examination, ultrasound or laparoscopy indicate thickening of the adnexa and stiff fallopian tubes (where the adnexal mass has hardened), it becomes even more necessary to break through accumulation of phlegm and blood stasis. Either pungent-warm E Zhu (Curcumae Rhizoma) 6-10g or neutral San Leng (Sparganii Rhizoma) 10g can be added according to the innate temperature of the patient. Salty-cold Hai Zao (Sargassum) 10g or sweet-bland-neutral Tu Fu Ling (Smilacis glabrae Rhizoma) 15-30g can also be added to clear stubborn phlegm masses.
- If there is excessive vaginal discharge, the practitioner must not use astringent herbs which would aggravate the dampness. If the tongue is purple red, bitter-cold Qu Mai (Dianthi Herba) 10g will invigorate blood and promote urination to drain excess damp. If the tongue shows less heat, sweet- cold Che Qian Zi (Plantaginis Semen) 10g or bitter- neutral Bi Xie (Dioscoreae hypoglaucae Rhizoma) 10-15g can be used to drain excess dampness through the urine.
- If the period is delayed, add more herbs with a descending action that invigorate blood and promote urination. Bitter-neutral blood invigorating Chuan Niu Xi (Cyathulae Radix) 15g, mild-cold Yi Mu Cao (Leonuri Herba) 10g, bitter- pungent-mild-warm Ze Lan (Herba Lycopi Lucidi) 10g, warm Chuan Xiong (Chuanxiong Rhizoma) 6g or Ji Xue Teng (Spatholobi Caulis) can be added as appropriate.
- If there is dysmenorrhoea, the period formula Tiao Jing Fang (Regulate the Menses Formula) can be started three days before the period is due and continued throughout the period to control pain and bleeding (see Chapter 13: Dysmenorrhoea and Chapter 4: Regulating the period for more details).
Acupuncture treatment is focused on draining damp, transforming phlegm, moving fluids in the lower jiao, reviving the Spleen and invigorating blood. In most cases of tubal obstruction, acupuncture alone is unlikely to be sufficient and both internal and external herbal medicine will be necessary. For those patients receiving surgery, acupuncture can be given before and afterwards to regulate qi and blood and thereby assist with conception. Needle technique is reducing to drain damp, transform phlegm, spread qi and invigorate blood, and reinforcing to tonify the Spleen.
- To drain damp and transform phlegm: Sanyinjiao SP-6, Yinlingquan SP-9, Fenglong ST-40.
- To tonify Spleen qi: Taibai SP-3, Gongsun SP-4, Zusanli ST-36, Zhongwan REN-12, Pishu BL-20, Weishu BL-21.
- To move fluids in the lower jiao: Zhongji REN-3, Shimen REN-5, Qihai REN-6, Shuifen REN-9, Youmen KID-21, Tianshu ST-25, Shuidao ST-28, Guilai ST-29, Ligou LIV-5, Ququan LIV-8.
- To invigorate blood: Diji SP-8, Xuehai SP-10, Taichong LIV-3, Geshu BL-17, Siman KID-14.
- To activate the Dai mai to move fluids in the lower jiao: Waiguan SJ-5 and Zulinqi GB-41, Daimai GB-26, Wushu GB-27, Weidai GB-28.
Blood stasis and fire toxin
The cycle is shortened and accompanied by bright- red or dark-red and clotted profuse bleeding. Vaginal discharge is heavy, sticky, yellow and/or blood tinged with a distinctly bad odour. There is severe abdominal pain which is aggravated by work pressures or emotional stress. The patient is flushed, complains of a bitter taste, a dry mouth, constipation, dark scanty urine or chronic urinary tract infections. There may be a diagnosis of acute pelvic inflammatory disease, a history of sub-acute PID or chronic pelvic pain, endometriosis or sexually transmitted disease.
Tongue: dark red with raised red spots at the rear and a yellow coating.
Pulse: slippery and rapid.
Clear heat and fire-toxins, invigorate blood to remove obstruction from the collaterals and open the bao luo.
Qing Re Tong Luo Fang (清热通络方, Clear Heat and Toxin to Open the Collaterals, Dr. Wu’s own formula)
Pu Gong Ying (Taraxaci Herba) 15g Lian Qiao (Forsythiae Fructus) 15g
Ren Dong Teng (Lonicerae Caulis) 15-20g Hong Teng (Sargentodoxae Caulis) 15-30g Bai Jiang Cao (Patriniae Herba) 15-20g Chi Shao (Paeoniae Radix Rubra) 10g
Dan Shen (Salviae miltiorrhizae Radix) 15g San Leng (Sparganii Rhizoma) 6-10g
E Zhu (Curcumae Rhizoma) 3-10g
Lu Lu Tong (Liquidambaris Fructus) 10g
The tubal obstruction here is caused by the condensing effect of heat on blood and body fluids. This formula combines herbs which clear heat and fire-toxin with those which invigorate blood and break through obstruction. Bitter-cold Pu Gong Ying and bitter-mild-cold Lian Qiao clear heat and reduce swelling. Pu Gong Ying combines with Lu Lu Tong to drain heat through the urine. Bitter- neutral Lu Lu Tong and Hong Teng, and cold-sweet Ren Dong Teng, invigorate blood and travel through the collaterals to clear the physical obstruction. Pungent- bitter-cool Bai Jiang Cao clears heat, invigorates blood and alleviates pain. Mild-cold Chi Shao nourishes, cools and invigorates blood. Pungent-cool Dan Shen, bitter-neutral San Leng and pungent-warm E Zhu have a strong action on blood stasis, with E Zhu’s warmth used to counterbalance the cooler herbs.
- If there is yellow vaginal discharge with itching and a thick yellow greasy tongue coating, add Huang Bai (Phellodendri Cortex) 6-10g or Qu Mai (Dianthi Herba) 6-15g. Qu Mai drains damp and heat through the urine, but since it also invigorates blood it must be used with caution in cases where there is a short cycle.
- If there is subacute pelvic inflammatory disease with pain, a sensation of fever and a yellow vaginal discharge, add Huang Bai (Phellodendri Cortex) 6-10g, Ye Ju Hua (Chrysanthemi indici Flos) 15-20g and Zi Hua Di Ding (Violae Herba) 10-15g to clear heat and fire-toxin.
- If a sexually transitted disease has been diagnosed, add bitter-cold Huang Bai (Phellodendri Cortex) 6-12g, bitter-cold Ban Lan Gen (Radix Isatidis seu Baphicacanthi) 15g pungent-cool Yu Xing Cao (Houttuyniae Herba) 15-20g and/or bitter-sweet- cold Bai Hua She She Cao (Hedyotis diffusae Herba).
- If there is constipation, use either bitter-cold Da Huang (Rhei Radix et Rhizoma) 3-12g (added at the end of cooking) or bitter-cool Zhi Shi (Aurantii Fructus immaturus) 6-10g to spread qi and clear fire toxin through the stool.
- If the cycle remains short, it may be necessary to modify the formula by reducing the dosage of the blood invigorating herbs and adding cold Ma Chi Xian (Herba Portulacae) 10-15g which clears fire- toxin and stops bleeding, and bitter-cold Chun Gen Pi (Ailanthi cortex) 6-10g which clears damp and heat and stops bleeding.
- If the cycle is still short, remove Chi Shao, Dan Shen and San Leng and replace with bitter-cold Qian Cao Gen (Radix Rubiae Cordifoliae) or Qian Cao Tan (carbonised Radix Rubiae Cordifoliae) 10- 15g, and sweet-neutral Pu Huang Tan (carbonised Pollen Typhae) 10g or Ou Jie (Nelumbinis Nodus rhizomatis) 15g.
- This formula, with its bitter-cold herbs, needs to be stopped two to three days before the onset of the period and replaced by a modified version of Tiao Jing Fang (Regulate the Menses Formula) which should be continued throughout the period to control pain and bleeding (see Chapter 13: Dysmenorrhoea and Chapter 4: Regulating the period for more details).
Acupuncture treatment is focused on clearing heat, cooling and invigorating blood and alleviating abdominal pain. In most cases acupuncture alone is unlikely to be sufficient and both internal and external herbal medicine will be needed. For patients receiving surgery, acupuncture treatment can be used pre- and post- surgery to regulate qi and blood and thereby assist with conception. Reducing needle technique is recommended.
- To clear heat and cool the blood: Quchi L.I.-11, Dadun LIV-1, Xingjian LIV-2, Ligou LIV-5, Ququan LIV-8, Yingu KID-10, Geshu BL-17.
- To spread qi, invigorate blood in the lower jiao and alleviate pain: Taichong LIV-3 combined with Hegu L.I.-4 (the ‘Four Gates’), Sanyinjiao SP-6, Diji SP-8, Xuehai SP-10, Zhongdu LIV-6, Zhongji REN- 3, Qihai REN-6, Yinjiao REN-7, Tianshu ST-25, Shuidao ST-28, Guilai ST-29, Ganshu BL-18.
- To activate the Chong mai to regulate blood: Gongsun SP-4 combined with Neiguan P-6, Qichong ST-30, Siman KID-14, Huangshu KID-16.
- To regulate the lower jiao: Yinlingquan SP-9, Fenglong ST-40, Yanglingquan GB-34, Daimai GB-26, Zhongji REN-3, Shimen REN-5, Qihai REN-6, Shuifen REN-9, Youmen KID-21, Shuidao ST-28, Guilai ST-29.
It is essential to combine external treatment with internal herbal medicine to treat tubal obstruction effectively. A range of out-patient or home-based external treatments is used in modern China. They include herbal enemas, uterine cavity perfusion and iontophoresis (where a medicine is administered through the skin via a mild electric charge). The most practical external methods for practitioners in Western countries are patient- administered herbal enemas or herbal compresses used directly on the abdomen.
Retention enemas are condensed decoctions with the medicine introduced into the body via the rectum. They are stronger than decoctions or powders taken orally and have the advantage that they are directly and rapidly absorbed into the blood stream local to the diseased area. They also have the advantage of being able to include hard- to-digest substances such as Tu Bie Chong (Eupolyphaga/ Steleophaga), Mo Yao (Myrrha) and Ru Xiang (Olibanum) at high doses without the side effects such as nausea that can sometimes accompany oral consumption. Retention enemas are normally used alongside oral decoctions.
Dang Gui (Angelicae sinensis Radix) 15g Ru Xiang (Olibanum) 10g
Mo Yao (Myrrha) 10g
San Leng (Sparganii Rhizoma) 15g E Zhu (Curcumae Rhizoma) 15g
Tu Bie Chong (Eupolyphaga/Steleophaga) 10g Lu Lu Tong (Liquidambaris Fructus) 15g
Xi Xin (Asari Herba) 5g, or if forbidden replace with Gui Zhi (Cinnamomi Ramulus) 10g
Pungent-warm Dang Gui nourishes and invigorates blood. To address the tubal obstruction, strong blood breaking substances such as pungent-warm Ru Xiang, neutral Mo Yao, pungent-neutral San Leng and pungent-warm E Zhu are needed. They all also alleviate pain. In order to further strongly break up blood, salty-cold Tu Bie Chong is used. Bitter-neutral Lu Lu Tong invigorates blood and promotes movement in the channels to assist in clearing obstruction. Pungent-warm qi moving Xi Xin (Asari Herba) or sweet- pungent-warm Gui Zhi (Cinnamomi Ramulus) 6-10g move through and open the channels.
In order to reduce side-effects and increase efficacy, oral decoctions and enemas are often given at the same time. When doing so, it is best to avoid using the same strong action herbs in both. For example, if Tu Bie Chong is included in the oral decoction, change it to Shui Zhi (Hirudo) or Meng Chong (Tabanus) in the enema. If San Leng is in the oral decoction, then replace with E Zhu in the enema. Since Ru Xiang and Mo Yao both strongly break up blood, alleviate pain and disperse swelling, they are very suitable for using in enemas but should never be included in oral decoctions at the same time in order to avoid causing nausea.
- If heat is evident, add bitter-mild-cold Lian Qiao (Forsythiae Fructus) 15g, sweet-cold Ren Dong Teng (Lonicerae Caulis) 30g or pungent-bitter-cool Bai Jiang Cao (Herba cum Radice Patriniae) 30g.
- If cold is evident add pungent-warm Xiao Hui Xiang (Foeniculi Fructus) 5-10g, pungent-warm Ai Ye (Artemisiae argyi Folium) 3-9g or pungent-warm Gui Zhi (Cinnamomi Ramulus) 6-10g if not already included.
- If phlegm-damp is evident, add pungent-warm Zao Jiao Ci (Gleditsiae Spina) 10-15g and bitter-cool Dan Nan Xing (Pulvis Arisaemae cum Felle Bovis) 6-10g.
- If there is severe abdominal pain add Jin Ling Zi San (Melia Toosendan Powder) comprising pungent- warm Yan Hu Suo (Corydalis Rhizoma) 15g and cold bitter Chuan Lian Zi (Toosendan Fructus) 6-9g or bitter-neutral Hong Teng (Sargentodoxae Caulis) 30-40g.
- If there is a confirmed hydrosalpinx add neutral Tu Fu Ling (Smilacis glabrae Rhizoma) 15-30g or cold Che Qian Zi (Plantaginis Semen) 10-15g.
Method of preparation and application
In order to save time, two bags are cooked together and the liquid kept in the fridge to be warmed before use each evening.
The herbs are soaked for 60 minutes and cooked with enough water to cover them by about 3cm. Total liquid is then reduced by cooking to around 250-300ml. This is then used over two days with about 125-150ml per application. The patient should pass urine and ideally stool before proceeding.
The decoction is taken from the fridge and warmed. The temperature should be around 38°C (or comfortable to an elbow dipped into it). A 12 or 14 gauge urine catheter is fed either from a drip bag or from a 100ml syringe. The catheter must be inserted 16 to 18 centimetres into the rectum. Liquid is either fed in or pushed in by the syringe. This must be done slowly since the enema is designed to be retained overnight and, if done too quickly, the patient may not be able to hold in the liquid. Similarly, if a drip bag is used, it should not be hung too high so that the enema goes in slowly and is thus more easily retained. Once the liquid has been inserted, the catheter is removed.
The enemas are started two to three days after the period has finished and are used either daily or every other day for a total of 10 to 15 days in each cycle. Repetition over three cycles is considered as one course of treatment. The results of the enema can then be checked by HSG. For further information see clinical notes below.
The boiled herbs used to make the decoction are mixed with yellow wine (huangjiu) to help them penetrate the skin. They are then wrapped in cotton or cheese cloth, steamed until hot, and applied to the abdomen over the fallopian tubes after the period has finished, for a total of 10-15 days in the cycle. If they are too hot, a towel can be used between the wrapped herbs and the skin. They should be retained for 20-30 minutes each time, and a hot water bottle can be placed on top of the compress to keep it warm.
It takes at least two to three months to treat tubal obstruction, and oral prescriptions must be combined with external treatment. A repeated HSG can reassess the patency of tubes after a course of treatment. If the fallopian tubes have cleared, the patient can then try to become pregnant and the practitioner can resume treatment by following the phases of the menstrual cycle if the patient is ovulating (see Chapter 3: Core Strategies for Treating Female Infertility). If the tubal blockage has been reduced but is still there, surgery may be necessary, although it can now be much less invasive since thickened tissue and scarring should have softened so that it is easier for salpingoplasty to restore tubal function. If after three courses of treatment the tubes remain blocked, either IVF or further surgery should be considered. Chinese medicine, however, can still be used to address the underlying disorder and to prepare for the treatment option chosen.
Biomedicine by Dr. Michael Haeberle
The fallopian tubes play a vital role in conception as human life first begins here. Each part of the fallopian tubes performs distinct vital functions. After ovulation the fimbria (the distal part of the tubes) retrieve the egg from the ovaries. The egg is then transported by the ciliated mucosa through the ampulla which is where fertilisation occurs (about 18 hours after ovulation) until the ampullary-isthmic junction is reached.2 The isthmus is the proximal part of the tubes (closest to the uterus). The diminishing diameter of the isthmic lumen causes the egg to lodge at the ampullary-isthmic junction before entering the uterus as a blastocyst. Once the embryo enters the isthmus, contractions of the fallopian tube cause the embryo to move, and after a further 48 hours propel the embryo into the endometrial cavity.3 Egg transportation throughout the fallopian tube is facilitated by the hair-like cilia which line the interior of the tubes and beat in waves hundreds of times a second.
Causes of tubal infertility
Fallopian tube disease is a major cause of infertility and may be congenital or acquired. Acquired tubal disease is usually inflammatory in nature and is most frequently secondary to PID. Other aetiologies include endometriosis, prior abdominal or pelvic surgery, salpingitis isthmica nodosa, appendiceal rupture and infection by tuberculosis.4
Infections and pelvic inflammatory disease (PID) Infections and PID are the most common causes of tubal infertility. Infections travel up through the uterus and the fallopian tubes, causing an intense inflammatory response within the tubes and the accumulation of bacteria, inflammatory cells and pus. Damage to the fallopian tubes from infection may lead to tubal mucosal scarring, adhesions outside the tubes and the ovaries, and tubal blockage (complete occlusion of the lumen of the fallopian tube, distally, proximally or both). Infections most commonly related to infertility include gonorrhoea, chlamydia and mixed pelvic inflammatory disease. Tuberculosis is also a common cause in Third World nations. The sequelae resulting from these infections include ectopic pregnancy, infertility, hydrosalpinx, chronic pelvic pain and tubo-ovarian abscess.
The incidence of tubal damage after one episode of pelvic infection is approximately 12 per cent, after two infections 23 per cent, and after three episodes 54 per cent.5 Huge cultural and geographical differences in pelvic inflammatory infertility are seen. Of all couples suffering from infertility studied, 49 per cent of African couples and 11 to 15 per cent of couples in other parts of the world had infectious tubal disease.6
Causes other than PID are associated with an increased risk of tubal damage. A history of complicated appendicitis increases the risk 7.2 times, priorpelvic surgery by 3.6 times, previous ectopic pregnancy by 16 times, endometriosis by 5.9 times and the use of intrauterine copper devices (IUD) 3.3 times.7 8 Salpingitis isthmica nodosa is a rare cause of tubal damage, mostly of the cornual (isthmic) part of the fallopian tube. Its incidence in healthy, fertile women ranges from 0.6 to 11 per cent, but it is significantly more common after ectopic pregnancy if the fallopian tubes have been retained. It is considered to be of inflammatory or auto-inflammatory origin and sometimes other signs of pelvic infection, such as adhesions, coexist. This particular disease is progressive and can easily be diagnosed by hysterosalpingography (HSG).9
Some women may have abnormal congenital development of one or both fallopian tubes. The uterus may also be abnormal in these cases.
Imaging plays a key role in the diagnostic evaluation of women for infertility. In most cases, the imaging work- up begins with hystero-contrast sonography (HyCoSy) or hysterosalpingography (HSG) to evaluate fallopian tube patency. HyCoSy/HSG is not the most sensitive method for detecting fimbrial pathology and peritoneal adhesions but allows for visualisation of the interior architecture of the tube and is a useful screening test due to its minimal invasiveness. Women are often diagnosed during this first test as having completely blocked tubes, although this may be found to be incorrect after subsequent laparoscopy. Abnormal findings by HyCoSy or HSG therefore need further evaluation by laparoscopy.10 A first-line laparoscopy is only indicated in woman suspected of tubal pathology due to a history of pelvic inflammatory disease, complicated appendicitis or previous pelvic surgery. However, since spontaneous intrauterine pregnancies occur even in patients with bilateral tubal occlusion at laparoscopy, this technique should not be considered the gold standard diagnosis of tubal infertility. An intelligently combined approach for diagnosis of tubo-peritoneal-uterine infertility using hystersosalpingography, hysteroscopy and laparoscopy with chromopertubation is recommended and if tubal damage is confirmed, all three tests are frequently needed. The laparoscopy should be done by someone skilled in infertility surgery to ensure that maximum information is gained.11
The following tubal pathologies are commonly found after investigation.
- 1. Complete blockage of the fallopian tubes at one or more points
Total blockage is the least common type of tubal damage and is mainly the result of genital infections. It generally affects both tubes equally. The blockage can either be found closest to the uterus (proximal tubal occlusion), or distally at the fimbrial end (distal occlusion) where it can cause a hydrosalpinx due to a lack of drainage, or a combination of both types of occlusion can occur.
- 2. Adhesions/scarring causing partial blockage
Adhesions form at areas of the fallopian tubes that have been damaged by infection, surgery or endometriosis. The adhesions stick the tubes to the ovaries, uterus or bowel. Scarring can create partial blockage of the tubes such as in stenosis (narrowing) of the fimbria.
- 3. Complete damage of the tubal mucosa and muscular wall (pansalpingopathy)
The entire fallopian tube is damaged inside and outside. This is often seen in genital tuberculosis. Surgical repair in such cases is impossible.
Two treatment options for achieving pregnancy are available to infertile women with damaged fallopian tubes: reconstructive microsurgery or in vitro fertilisation (IVF). Both may be necessary to achieve a pregnancy. The choice of the most appropriate treatment depends on both technical and non-technical considerations.
Reconstructive surgery should be the first treatment option in patients with proximal tubal occlusion, tubal adhesions on the outside due to for example endometriosis (peritubal adhesions), narrowing (stenosis) of the fimbria and for reversal of tubal sterilisation. This is probably the most specialised branch of infertility treatment and the results can be excellent, depending on the skill of the surgeon.12 13 The results of microsurgical repair in proximal blockage or reversal of sterilisation give intra-uterine pregnancy rates between 30 and 70 per cent (depending on the age of the woman), and extra-uterine pregnancy rates of between two and nine per cent. Microsurgical removal of adhesions gives intrauterine pregnancy rates between 25 and 65 per cent (depending on the extent of the adhesions) and extrauterine (ectopic) pregnancy rates of between five and 15 per cent. Microsurgical opening of hydrosalpinx (salpingostomy) results in 24 per cent intrauterine and 16 per cent extrauterine pregnancy, where couples try to conceive naturally.14 15 16 17 18
IVF is the only treatment option for women with inoperable fallopian tubes due to extensive damage. IVF is also associated with other important factors such as male infertility or failed microsurgery.
Combination of IVF and microsurgery
A combination of both treatments is most frequently given for tubal blockage due to a hydrosalpinx. The presence of a hydrosalpinx leads to a significant reduction in embryo implantation rate after IVF because the accumulated fluid in the hydrosalpinx suppresses implantation.19 Microsurgical salpingostomy (microsurgical opening) or salpingectomy (removal of the fallopian tube) or proximal clipping raises the implantation rate to normal values.20
Younger women may consider surgery first and IVF thereafter if necessary, whilst women between 37 and 40 years should consider IVF first or both therapies at once. Health insurance coverage and financial resources of the couple play important roles in their decision, as does the impact of a multiple pregnancy which occurs much more frequently with IVF. In terms of risk factors, ectopic pregnancy rates are higher after microsurgery than in IVF.
Case study from the clinic of Dr. Yuning Wu: Tubal infertility
05.2010. Mrs. Zhu, aged 40, came to my clinic prior to IVF since one previous round of IVF with three good quality embryo transfers had failed due to poor endometrial blood flow/receptivity. Both her fallopian tubes were completely blocked and she had suffered from secondary infertility for 10 years and was relying on IVF to conceive ...
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