Herbal Formula: If the woman is not so young (>35 years) or there is Kidney Yin deficiency, some extra herbs need to be added to the basic ovulation formula, Cu Pai Luan Tang. This then becomes Bu Shen Cu Pai Luan Tang and is useful if the Yin levels have not been quite brought up to ideal levels before ovulation or if there is weak Qi and Blood movement.

In comparison to Cu Pai Luan Tang, the first priority of this formula is supporting the Kidneys (Shu Di, Nu Zhen Zi, Bu Gu Zhi, Tu Si Zi), Spleen (Shan Yao) and Liver (Bai Shao). Moving the Blood (Wu Ling Zhi, Hong Hua, Dang Gui, Chi Shao, Mu Dan Pi) is secondary. Kidney Yin tonics support ovary function, Kidney Yang tonics promote maturation of the egg and reinforce its energy making capacity and Blood moving herbs promote development of the endometrium and ensure no obstruction to ovulation.

This formula is used for 3–5 days and, if successful, ovulation will occur and the basal body temperature pushed to its high level quickly and efficiently.

Acupuncture Points: Add to the points chosen from Table 4.5:

Use reinforcing technique.

Herbal Formula: In cases where there are generalized Kidney Yang deficient or Cold signs and symptoms we use warming and moving herbs to encourage effective ovulation. A formula like Wen Yang Hua Yu Fang can be used as the guiding formula here.

This formula introduces quite a lot of Heat with herbs such as Zhi Fu Zi and Gui Zhi, and movement of Blood with herbs such as Hong Hua, Chuan Xiong, Ji Xue Teng and Dang Gui. Huai Niu Xi, Shu Di and Yin Yang Huo support the Kidney Yin and Yang.

These herbs are taken for around 3 days at midcycle or from the day of supposed ovulation. If they are used too early they will dry the fertile mucus and the protective mucus lining of the tubes. Because they are very heating it is important to ensure there is no Liver- or Heart-Fire or Yin-deficient Heat present.

Where there is ovulation pain, which is relieved by warmth, add:

Acupuncture Points: Add to points chosen from Table 4.5:

Use reinforcing method and moxa.

Herbal Formula: A lack of Kidney Jing really needs to be addressed from the beginning of the cycle and there is little more that can be done now we are at midcycle if the Jing Qi is not sufficient, i.e., there will be no eggs ripe and ready for ovulation. However, if the Jing tonic herbs applied early in the cycle seem to be having results, i.e., more fertile mucus is appearing (or blood tests show that estrogen levels are rising adequately), then the guiding formula Bu Shen Cu Pai Luan Tang can be given around midcycle, with the addition of:

Acupuncture Points: Add to the choice of points in Table 4.5:

Use reinforcing method.

Any rise in the BBT after this treatment must be seen as very encouraging progress, because it indicates that an ovulation has occurred. However, the temperature may drop again quite soon or it may not reach a very high level and it may take many months of treatment before a good ovulation can be produced.

In fertility clinics in China, women are usually advised to establish reliable cycles and good ovulations (i.e., convincing BBT charts) before attempting pregnancy. However, in the case of women with Jing deficiency and a very erratic menstrual history, they will quite understandably want to take advantage of any ovulation at all since they are so few and far between. The risk, of course, is miscarriage, so I do try to persuade these women to wait a few months after commencing treatment before trying to conceive.

Herbal Formula: It is critical that Liver and Heart Qi remain unobstructed for ovulation to occur, so we must always pay great attention to these at this time of the cycle. Ovulation pain and breast or nipple tenderness alert us to stagnation of Liver Qi at this time. The liver (physiological organ) can be assisted by the following treatments to break down hormones without compromising estrogen production by the ovaries. This will usually be enough to stop symptoms of breast soreness.

In most cases, adding a few herbs to the base formula Cu Pai Luan Tang is enough to facilitate movement of Liver Qi and Heart Blood. For example:

However, if there is marked Heart or Liver Qi stagnation causing emotional disturbance, a stronger approach is necessary. A useful guiding formula is the following:

Yuan Zhi and Shi Chang Pu are combined here to quieten the mind during the ovulation phase. Yu Jin, Dan Shen, Chai Hu and He Huan Pi will support this action by removing Heart or Liver Qi stagnation. Liver and Heart Blood are reinforced with Dang Gui and Bai Shao. Chi Shao ensures that Liver-Heat is cleared and Fu Ling supports the Spleen function in the face of Liver Qi stagnation.

If such emotional instability is occurring in a woman with Kidney weakness (or she is over 35 years old) we should continue Kidney tonic herbs as well. The herbs listed above already include four of the herbs from our Kidney Yin deficiency ovulation formula (Bu Shen Cu Pai Luan Tang) and we could add several more. For example:

If the high levels of hormones, which can occur at ovulation (especially where there is Liver Qi stagnation) cause a sensation of fullness or aching in the vulva, then adding herbs to strengthen Spleen Qi is appropriate. Add to the appropriate base formula (Yuan Zhi Chang Pu Yin modified or Cu Pai Luan Tang modified):

Acupuncture Points: Acupuncture is undoubtedly useful at ovulation time and it is worth the patient making an effort to book visits to the acupuncturist’s clinic to coincide with this particular time.

Choose points from Table 4.5 which emphasize the movement of Qi in the fallopian tubes and ensure there is no tension or constriction in these fine muscles, i.e., choose local abdomen points and Liver channel points. Additionally, choose points which calm the mind and clear the Bao vessel, i.e., Heart and Pericardium channel points and Yintang and KI-4.

Use an even or reducing method.

Herbal Formula: The sorts of formulas we use at midcycle already contain Blood-moving herbs. In some cases we might want to add stronger herbs or increase the doses of ones already chosen.

Blood stagnation of the type that will seriously disrupt ovulation might include cysts or endometriomas on the ovary – these are likely to cause pain and therefore demand attention at midcycle. Some forms of tube blockage are caused by Blood stagnation – these are covered in Chapter 6. In the case of substantial obstructions, we usually use Blood-breaking herbs like E Zhu or San Leng although in cycles where conception is attempted these herbs may be too harsh. However in robust young women with significant masses that are obstructing the ovaries or the tubes these herbs may be added for just a couple of days and in small doses.

In the case of cysts or masses in a strong and young woman, Cu Pai Luan Tang can be modified by adding:

and increasing the dose of Wu Ling Zhi to 12 g, and Hong Hua to 9 g.

In the case of endometriomas (and if there is a component of Kidney deficiency) you can modify Bu Shen Cu Pai Luan Tang in exactly the same way.

Acupuncture Points: Consider including among the points chosen from Table 4.5:

and add:

Use with reducing method.

Herbal Formula: In most women and in most cycles, herbs which strongly move Qi and Blood to facilitate ovulation are applied only when we get to the point where the Yin is well established and the egg is ready to be launched, i.e., around Day 13 or 14 in a 28-day cycle. However, when Phlegm-Damp is seriously gluing up the works, we need to apply such treatment well before ovulation, otherwise the egg may never be released or, if it is, it will not get very far before being obstructed by excess or pathological mucus secretions in the fallopian tubes.

In women diagnosed with Phlegm-Damp we added to our base formula Yang tonics and Damp-clearing herbs in the early part of the cycle. Once we have some evidence that we have established a good enough basis of Yin (there is fertile mucus or blood tests show rising estrogen levels) we use a more strongly activating formula, even if it is only I week past the period. For example, the formula Wen Yang Hua Tan Fang will transform Damp and Phlegm, warm Yang and activate Qi and Blood.

This formula combines a strong heating element (Zhi Fu Zi) with Yang tonics (Xu Duan and Yin Yang Huo) and herbs which encourage elimination of Damp (Cang Zhu, Fu Ling, Chen Pi, Zhi Ke and Dan Nan Xing). Because it is an ovulation formula, Blood-regulating agents (Shan Zha and Hong Hua) are added. Dan Nan Xing is added here for its ability to dissipate lumps (in this case, obstructions in the tubes).

If the release of the egg from the ovary appears to be obstructed by Phlegm-Damp add:

Acupuncture Points: From the points chosen from Table 4.5, emphasize the Spleen channel and Dai vessel points and add:

Use with even or reducing method.

Herbal Formula: Rather than simply adding styptic herbs to our midcycle formula, chronic midcycle bleeding must be addressed by treating the imbalance at the early stages of the cycle so the uterine lining can be built after the period. For Yin deficiency with midcycle bleeding add:

and increase Shan Yao and Nu Zhen Zi to 15 g each in post-menstrual and midcycle formulas.

To the midcycle formula add:

With signs of Heat add:

Acupuncture Points: To points chosen from Table 4.4 add:

Herbal Formula: Ai Fu Nuan Gong Wan is the formula recommended in most classics to boost Kidney Yang and warm the uterus in the luteal phase. However, when it comes to raising progesterone levels, other approaches have in more recent times been found to be more effective.¹ One of three basic approaches can be taken, depending upon the tendency to Yin, Qi or Blood deficiency. Often it is the shape of the BBT chart that will help determine which approach should be taken to support Yang in the luteal phase.

Herbal Formula: Some of the famous classical Yin or Yang tonic formulas demonstrate the interdependence of Yin and Yang well, e.g., You Gui Wan, which is a well-known Yang tonic formula, contains not only the herbs for building Yang but also three Yin tonics. Therefore, to boost Yang by supplementing Yin, this formula is chosen as the guiding formula. It can be applied in the luteal phase to assist implantation and early fetal development even when there is no marked Kidney deficiency.

This formula includes the first three herbs of Liu Wei Di Huang Tang – Shu Di, Shan Yao and Shan Zhu Yu – which supplement, respectively, the Kidney, Spleen and Liver Yin. Tu Si Zi, Ba Ji Tian and Lu Jiao Pian reinforce Kidney Yang.

Acupuncture Points: In terms of channel activity the emphasis is now moving from the Chong to the Ren vessel. Ren vessel points can be chosen in the days after ovulation to encourage implantation. But once implantation is completed, i.e., in the week before the period, lower abdomen points are used with great caution (or avoided altogether by the less experienced practitioner). The use of Kidney points at this time maintains Kidney Yin and Yang. Choose points from (and see Table 4.6):

Herbal Formula: Traditionally, this syndrome has been treated with the formula Zhen Wu Tang, which strongly warms Kidney Yang and invigorates Spleen Qi. In gynecology departments, however, the preferred guiding formula is a modified version of Jian Gu Tang.

In this version of Jian Gu Tang, the primary herbs Dang Shen, Bai Zhu and Shan Yao are employed to invigorate the Spleen Qi. Yi Yi Ren reinforces this action and has the added affect of clearing any Damp that might have accumulated as a result of the Spleen weakness. Tu Si Zi, Ba Ji Tian and Lu Jiao Pian fortify Kidney Yang.

Acupuncture Points: Acupuncture treatment to promote Qi is useful in the 1st week after ovulation to ensure mobility and free passage of the embryo in the proximal part of the fallopian tube.

The process of implantation is a dynamic one which requires vigorous Qi as the embryo binds to the endometrium and then burrows into it. In addition, the uterine walls must be mobile enough to press together and hold the embryo securely as it undergoes implantation.

Choose points from the following (and see Table 4.7):

Herbal Formula: When both Kidney Yang and Blood must be fortified, we use Blood and Qi tonics in combination with Kidney Yang tonics.

This formula combines the Qi tonics of Si Jun Zi Tang (Dang Shen, Bai Zhu, Fu Ling and Gan Cao) and the Blood tonics of Si Wu Tang (Dang Gui, Bai Shao, Chuan Xiong and Shu Di) with Kidney Yang tonic herbs (Tu Si Zi, Du Zhong and Lu Jiao Pian).

Acupuncture Points: For successful implantation the endometrium must be both receptive and nourishing (i.e., have good blood circulation). The flow of blood to the endometrium has been shown to be increased by acupuncture.⁴ To encourage implantation we choose points which support Kidney function and increase production of Blood and which stimulate blood flow to the uterus (see Table 4.8), such as:

Herbal Formula: As you know, women with Kidney Yin deficiency often have problems with ovulation. It may be that they ovulate late or irregularly or that the egg released is of poor quality. However, it may also be that they ovulate ‘inadequately’. What this means is that the corpus luteum, created after the egg is released, functions poorly, i.e., it secretes inadequate levels of progesterone so that implantation will be unsuccessful. In Chinese medicine terms we say that deficient Kidney Yin cannot produce Kidney Yang.

To address this problem the preferred formula in most gynecology departments in China is a version of You Gui Wan (see method A above). To this can be added further Yin tonics if Kidney Yin deficiency is pronounced. For example, add:

Acupuncture Points: Choose points from Table 4.6 and emphasize the points which enhance Kidney Yin and clear Heat. For example:

and add:

Herbal Formula: Sometimes we can be completely reassured that Kidney Yin is adequate and yet the Kidney Yang is still showing signs of deficiency. This is demonstrated by BBT charts which rise convincingly from a good Yin foundation to a high temperature straight after ovulation but which fall rapidly thereafter, dwindling to a temperature not much more elevated than those of the first 2 weeks of the cycle. These low temperatures will continue to be recorded throughout the entire luteal phase until the period comes in 2 weeks (see Ch. 3).

A variant on this type of Kidney Yang deficiency is shown in the BBT chart in which the temperature rises minimally after ovulation (also seen in Kidney Yin-deficient pattern) and maintains this low reading until the period (see Ch. 3).

In this case it is a failure of Qi to promote Kidney Yang, specifically Spleen and Stomach Qi. Clinically, it is common to see Spleen Qi deficiency with Kidney Yang deficiency. The formula Jian Gu Tang (above) is used as the guiding formula in such cases with the addition of more Kidney Yang tonic herbs:

Acupuncture Points: Choose points from Table 4.6 and apply moxa, especially on Ren-4.

Herbal Formula: In most cases of Kidney Jing deficiency the focus of our treatment will be on the post-menstrual phase leading up to ovulation and then during the ovulation event itself. If treatment has been successful and an egg has been sufficiently ripened and then released, it will usually be enough to just maintain the momentum by using a formula like You Gui Wan with the addition of Jing nourishing herbs. For example:

Acupuncture Points: Choose points from Table 4.6; moxa can be applied to Ren-4.

Herbal Formula: The guiding formula to strengthen Kidney Yang and nourish Blood is Yu Lin Zhu (formula given above). For women who are prone to Liver Qi stagnation premenstrually (PMS or premenstrual syndrome), it is advisable to add to this formula herbs to regulate Liver Qi. For example:

In the case where Liver Qi stagnation gives rise to Liver-Fire, Heat-clearing herbs must be added. The use of strong doses of Kidney Yang tonics for more than I week also brings with it the risk of feeding Liver-Fire and exacerbating premenstrual symptoms. If this occurs, the patent medicine Dan Zhi Xiao Yao San is given or some cooling herbs are added to the formula Yu Lin Zhu, such as

The BBT chart is scrutinized closely to see that these herbs do not lower the temperature too much and jeopardize the luteal phase.

The use of Qi- and Blood-regulating herbs is controversial in the luteal phase if the woman is trying to fall pregnant, and some practitioners will avoid such herbs completely. However, as was mentioned earlier, some others find that the inclusion of Qi-regulating and mild Blood-regulating herbs can be useful in facilitating implantation and at the same time can calm the mind. For example:

Once the period is delayed and pregnancy suspected or confirmed, such herbs should be discontinued unless there is significant Blood stagnation.

Acupuncture Points: In addition to considering points in Table 4.8, that encourage Liver and Heart Blood formation, choose some points that regulate Liver and Heart Qi (see Table 4.9). For example:

Herbal Formula: Blood stagnation impacts on ovulation or implantation. When we are considering the effect of Blood stagnation on implantation it is the nature and quality of the endometrium and any disturbances therein which concerns us.

The most obvious impediment to implantation by Blood stagnation is the presence of large fibroids that protrude significantly into the endometrial layer and uterine cavity. If much of the endometrial surface is affected by large or numerous fibroids, then there are limited sites for implantation and development of the placenta. Also, bodies such as polyps inside the uterus can have the effect of an intrauterine device (IUD) and interfere with endometrial development and implantation. Uterine polyps and fibroids can also interfere with implantation if they stick so far out into the uterine cavity to prevent the front and back walls of the inside of the uterus pressing together to help the embryo get a foothold while implanting. Poor circulation, sluggish movement of blood and metabolites, and incomplete development of the spiral blood vessels of the endometrium are all more subtle ways that Blood stagnation might hinder implantation and development of an embryo.

Although Kidney Yang is not implicated so directly here, it is nevertheless important in moving Blood in the lower Jiao. Treatments applied to clear Blood stasis to enhance fertility should also include herbs to boost Yang. Thus, we can use the guiding formula Yu Lin Zhu (see method C above) but modify it to include more Blood-regulating herbs. This formula should be taken in the luteal phase for several menstrual cycles during which time pregnancy attempts must be avoided. Of course, in situations of substantial Blood stagnation, such as large fibroids or polyps, it makes good sense to remove them with surgery (or with strong herbal treatment) and only attempt pregnancy after they are resolved.

Yu Lin Zhu was described earlier. Additions include San Leng and E Zhu, which strongly break up stagnant Blood.

If a patient is determined to continue attempts to conceive, then Yu Lin Zhu is used with the addition of Blood-moving herbs which are milder. San Leng, E Zhu, Mo Yao, Ru Xiang and Chi Shao will be replaced with:

However, these herbs are unlikely to be effective in reducing large mechanical obstructions.

Acupuncture Points: Choose points from Table 4.8 and add some regulating points (see Table 4.10). For example:

Treatment of severe Blood stagnation in infertility does not always stop when pregnancy is achieved: often the stagnation must be addressed throughout the pregnancy too.

Herbal Formula: If Kidney Yang is deficient it is much easier for fluid to accumulate and eventually Phlegm-Damp forms. Whereas the manifestations of Phlegm-Damp can interfere significantly with the processes necessary for a successful pregnancy, they are the Biao and not the Ben, i.e., they are not the fundamental underlying disorder causing the infertility. Treatment will therefore concentrate on building Yang while at the same time clearing Phlegm-Damp.

Most interference by Phlegm-Damp happens on the ovaries (e.g., polycystic ovaries) or in the tubes (tubes obstructed by mucus or fluid). An excessively mucusy or slippery surface on the endometrium may also hamper implantation. For this reason, it is important to maintain some Phlegm-Damp clearing treatment in a woman with a Damp constitution as implantation is being attempted. And it is even more crucial if there is fluid trapped in the tube (a hydrosalpinx), which may flood the uterus just at the time implantation is attempted (see Ch. 5).

To maintain Kidney Yang and clear Phlegm-Damp in the luteal phase, use method B, the Jian Gu Tang method, with the addition of Damp-clearing herbs and replacing Lu Jiao Pian with Yin Yang Huo. Because Phlegm-Damp can cause pronounced obstructions, this formula includes herbs which unblock channels and clear Blood stasis in addition to those which remove Phlegm-Damp.

Jian Gu Tang was used previously in the treatment of Kidney Yang and Spleen Qi deficiency in the luteal phase. This modified version adds herbs which are drying (Yin Yang Huo and Shi Chang Pu) and herbs which can break through Phlegm-Damp obstructions and free the channels (Dan Nan Xing, Di Long and Lu Lu Tong). Wang Bu Liu Xing supports this action by clearing Blood stasis.

Acupuncture Points: Choose points from Table 4.7 which boost Qi and Yang. In addition consider the following points (and see Table 4.11):

Acupuncture Points: Acupuncture is the treatment of choice for morning sickness and is often very effective, although it may need to be repeated frequently (even daily) in more severe cases. Medical researchers have experimented with applying pressure to the point Neiguan PC-6 on women experiencing morning sickness.⁶ Significant and continued reduction of nausea compared to use of a placebo point was reported.

In the acupuncture clinic, we use the following points (and see Table 4.13), which regulate the rising Qi of the Chong channel and encourage Stomach Qi to descend:

Use with reinforcing or even method.

If there are emotional or stress-related components add:

Use with even or reducing method.

If the Stomach Qi is weak, add:

Use reinforcing method.

If there is vomiting of mucus, add:

Herbal Formula: Herbal remedies for morning sickness are described in Chinese medicine texts but it takes a very strong-minded patient to swallow herbal decoctions when her stomach is rejecting most foods. Even the smell of many Chinese herbal decoctions provokes nausea. Hence, I have included here only one of the many text-listed morning sickness formulas. The following formula addresses most of the causes of severe morning sickness – namely, rising Stomach Qi, accumulation of Phlegm and Liver Qi stagnation. If nausea and vomiting are severe and the fetus is at risk, give this formula in small amounts, in combination with cupping or Gua Sha described below. A granulated form of the herbs can be put in capsules if the smell and taste are too repugnant.

This formula is a variation of Su Ye Huang Lian Tang, a popular morning sickness formula, which harmonizes Liver and Stomach. Zi Su Ye, Ban Xia, Sheng Jiang and Chen Pi all harmonize the center to suppress vomiting. Huang Lian clears Heat, calms the Stomach and prevents vomiting. Gou Teng pacifies the Liver and Huang Qin settles the fetus.

If severe vomiting persists, add:

Cupping the point Ren-12 Zhongwan strongly for 15 min will sometimes pacify the rising Stomach Qi long enough to drink and absorb some herbs.

Rubbing the skin, a technique known as Gua Sha, on the points

each day or every 2nd day can also relieve severe vomiting long enough to ingest small amounts of herbs to resolve morning sickness.

Ginger on its own is a recognized and effective remedy for morning sickness. Even at doses as low as 1 g/day symptoms can be relieved, but the ginger has to be taken a minimum of 48 h up to 4 days before it becomes effective.

There are many pregnancy conditions which respond well to acupuncture and these are covered thoroughly in texts dedicated to obstetric acupuncture.^7,8

Acupuncture Points: Acupuncture may be of benefit if the position of the baby is not good for delivery. Seeing very pregnant women at the acupuncture departments of Chinese hospitals is not at all rare. They come any time after 34 weeks if their baby has not turned into a head-down position. Moxa treatment is applied for 15 min each day to just one point:

The treatment may need to be repeated five or more times before the baby turns and adopts a cephalic position. It is most common for the pregnant woman to report increased activity in the womb and sometimes to actually feel the baby turn during the night when she is resting. If there is some physical impediment to its moving (e.g., fibroids or placement of placenta and umbilical cord) then the moxibustion will have no effect. This time-honored technique has recently been assessed favorably in clinical trials.^9,10 The simplicity of the treatment and easy diagnosis of the condition and its outcome without the necessity of a TCM analysis makes this one of the few conditions which is easy to analyze according to the criteria of Western science.

Midwives often recommend their patients have acupuncture in the month before the due date since this approach appears to significantly reduce the number of medical inductions, epidurals and emergency cesareans.¹¹ Acupuncture frequency may be increased if the patient is past her due date and is facing medical induction of labor. It has also been shown that electro-acupuncture is just as effective as the use of prostaglandin gel in ripening the cervix. This study also found that there were fewer cesarean deliveries and obstetric complications when acupuncture was used to induce labor.¹²

The main points are (and see Table 4.14):

A gentle electric current is often applied to these points, especially SP-6.

Other useful points are:

And here with, the birth of a red squirming baby, ends this chapter!