Gynecologic disorders which can cause infertility

• Brown or pigmented endometriosis appears as small dark brown spots. The blood lost from this endometrial tissue during the time of menstruation has nowhere to go and gets trapped and may cause pain, depending on the site of implantation. The old dried blood then gives these spots a dark brown appearance. These peritoneal lesions are most active when they are superficial and hemorrhagic and become less active over time as dead and fibrotic tissue forms.

• Chocolate cyst is the name given to endometriosis which forms a cyst in the ovary. The blood from this tissue is encapsulated in a cyst and becomes thick and dark brown and appears like chocolate.

• Pale pink, white or non-pigmented endometriosis looks like pale lesions on the surface of different parts of the pelvic cavity. These lesions have not yet become brown because they have not developed far enough to bleed, but they seem to be active in secreting substances which inhibit conception. They may also be more active in producing prostaglandins and be associated with more pain than older lesions. It can take 7–10 years for these lesions to become red and then dark as they age and become fibrotic.

• superficial endometriosis sits on the surface of the membrane and seems to be more implicated in infertility

• deeper endometriosis penetrates a few millimeters into the membrane and the underlying tissues and causes pain.

Distortion of the Position of Tubes or Ovaries

If there is a significant amount of endometriosis in an inconvenient place, near the fallopian tubes or ovaries for example, it is not difficult to see how the distortions it causes could prevent conceptions by preventing the egg and the sperm meeting. Over time, the fallopian tubes may become inflamed and blocked by adhesions. Thus, ectopic pregnancies are more common in women with endometriosis. Even mild endometriosis is associated in most cases with peri-ovarian adhesions which may interfere with ovulation or transport of the egg between ovary and fallopian tube.³

Immune Dysfunction

Endometriosis is characterized by a low-grade inflammation in the pelvis, which manifests as an increase in peritoneal fluid, increased number of macrophages and their secretions, i.e. prostaglandins, proteolytic enzymes and cytokines.⁴

Macrophages are large cells which mop up cellular debris and bacteria and other foreign material; one of their jobs is to kill off sperm that swim all the way out of the tubes and into the abdomen. When there is endometriosis present, there are increased numbers of macrophages⁵ which become more active and go on their seek and destroy missions with great vigor. Unfortunately, these vigilantes can enter the fallopian tubes and pick off sperm before they have had a chance to meet the egg. In women with partners who have poor sperm counts, this can be quite disastrous, leaving no sperm at all to fertilize the egg. Additionally, the cytokines which macrophages produce are toxic to sperm affecting their mobility and ability to fertilize the egg, providing yet another impediment to fertility.^6,7 Cytokines and chemokines such as tumor necrosis factor-alpha, and interleukins IL-1, IL-6, IL-8, etc. contribute to the pathogenesis of endometriosis by enhancing attachment, angiogenesis and/or proliferation of ectopic endometrial tissues in the pelvis.⁸

The disease is further characterized by impaired T-cell mediated cytotoxicity, natural killer (NK) cell activity and B-cell function.

Production of Secretions which Obstruct Fallopian Tubes

The type of endometriosis that sits superficially on the membrane surrounding the pelvic structures has been shown to have glands similar to that found in the endometrium. These glands secrete mucus. This mucus can coat the fimbriae or the ovary, preventing the transfer of the egg to the tube. Such a phenomenon has been observed in animal studies.⁹

Increased Prostaglandin Production

Endometriosis is associated with increased levels of prostaglandins (PGE₂ and PGF), which may have a deleterious effect on the patency and flexibility of the fallopian tubes. Muscular contractions of the uterus are also increased causing pain and possibly interfering with implantation.¹⁰

LUFS and Low Progesterone

Endometriosis is associated with a higher incidence of the ovulatory disturbance called luteinized unruptured follicle syndrome (LUFS) and lower progesterone levels in the luteal phase.

Things can go awry just before ovulation if luteinizing hormone (LH) levels are less than adequate. A developing follicle may respond to the extent that it forms a corpus luteum and produces progesterone but there is not enough LH to soften the follicle casing and allow the release of a mature egg. A luteinized unruptured follicle (or LUF) is formed. The amount of progesterone this LUF produces is often less than usual and for fewer days, and is the basis of an inadequate luteal phase or luteal phase defect. Obviously, conception is impossible in such cycles since there is no egg released, and even if there were, the progesterone support is such that implantation and development of an embryo is unlikely. It is estimated that endometriosis results in anovulation in up to 20% of cycles of some patients.

Endometrial Changes and Reduced Implantation Rates

Although appearing histologically normal, the endometrium and inner myometrium (the junctional zone) in women with endometriosis and adenomyosis show marked functional disturbances. The lining has aberrant responses to ovarian hormones such that factors important for implantation are affected.^10,11 Implantation and placentation involve deep invasion of the junctional zone and it may be the failure to do this properly that accounts for the increase in premature births and other adverse pregnancy outcomes seen in women with endometriosis.¹²

Disruption in the deepest layer of the endometrium may also explain functional abnormalities such as hyperperistalsis, dysperistalsis and inordinate smooth muscle proliferation associated with endometriosis and adenomyosis which can affect the way sperm are transported.¹³

Other studies have suggested that there are disruptions to shedding of the uterine lining during menstruation in endometriosis sufferers, which leads to abnormalities in the uterine lining in the subsequent luteal phase.¹⁴

All of the above possibly contribute to the observed reduced embryo implantation rate.¹⁵

Reduced Oocyte Quality

Studies with IVF patients receiving donor eggs have shown that success rates were reduced when the oocytes were from women with endometriosis indicating that the disease affected in some way the quality of the donated oocytes.¹⁶

Ovarian Reserve may be Lower in Endometriosis

Studies on infertile women with mild or minimal endometriosis show reduced ovarian reserve (measured by AMH). Whether this is an association or a cause is not known.¹⁷ Surgical removal of endometriomas can also have a deleterious effect on ovarian reserve (measured by AMH).¹⁸

Diagnosing Endometriosis

Endometriosis, as you may have gathered, is a multifarious type of disorder which can manifest in many guises. Sometimes, there are no bothersome symptoms at all. Often there is period pain and sometimes there is also pain with intercourse. Infertility is involved in some cases and not in others. And the ways that endometriosis contributes to infertility is at many different levels, the quality of the eggs, the integrity of the uterine lining, the way the tubes and uterus move, the distortion of tubes or ovaries or the inflammation and over-activity of the immune system. Any diagnosis a Chinese medicine doctor comes up with, should keep in mind all these possibilities. Figure 5.1 outlines some of the etiologic relationships relevant to the development of endometriosis.

There are some characteristic signs that are recognized by doctors working in infertility clinics in China, which will alert them to the possible presence of endometriosis. These are distinctive patterns on the basal body temperature (BBT) charts (see below) and spotting before periods, which is also recognized by Western doctors as strongly indicative of endometriosis. These two signs, together with some of the clinical symptoms mentioned earlier – especially period pain getting worse with age and accompanied by a bearing-down sensation in the abdomen or palpation of nodules along the sacrospinal ligament – constitute as definite a diagnosis of endometriosis that a doctor working in China without a laparoscope can reach.

It must then be remembered that to a TCM doctor, the unique and individual presentation of each patient is what will determine the appropriate treatment.

BBT Patterns

You will recall from our discussions in Chapter 3 that the typical BBT chart has a low phase, which begins at (or just prior to) the beginning of the period, and a high phase, which begins at ovulation and persists until the next period. The two changes to this pattern which can suggest endometriosis are:

Targeting the Lesion

The emphasis of TCM treatment for endometriosis usually involves clearing Blood stagnation. Endometriosis is a Western medical label not a TCM one, but the scientific medical understanding of this disease has contributed to the notion that this is a disease characterized by blood being where it shouldn’t and unable to escape the body, i.e., what we call Blood stasis. Symptoms such as severe stabbing period pain, clotty menstrual flow and palpable nodules or masses in the abdomen verify the diagnosis of stagnant Blood.

The mark of a skilful doctor is to keep close sight of exactly what requires changing, maintaining awareness of the constellation in which it appears. In the case of endometriosis the central part of the picture is the lesion which can manifest in various guises:

Table 5.1 lists the theoretical relationship between these different types of lesions and their treatment principles.

Treatment to target implants of endometriosis (Zheng Jia, or masses, in TCM) involves the use of heavy handed ‘Blood busting’ herbs and those that reduce inflammation by clearing Damp and Heat. Table 5.2 lists some of these herbs and substances. (See also Appendix 2.)

We can incorporate these substances in potent formulas designed to break down endometriosis tissue. Such formulas are only used short term, and often just at or near the time of greatest pain, usually the period. Some of these animal products are toxic and are used in small doses for a specific time for a specific purpose. Wu Ling Zhi, however, is one substance that can be used in the longer term and in women of weak constitutions with Blood stasis. We shall see the use of some of these substances in formulas used during the period.

Treating Infertility Associated with Endometriosis

Most of our discussion of treatment will however be somewhat broader than a narrow focus on breaking down endometriosis tissue. As Western medical researchers discovered more about this disease, so did TCM doctors, who developed their treatment protocols of infertility caused by endometriosis, in different directions. For example, in the infertility clinics in China, doctors found that more pregnancies resulted if treatment of women with endometriosis targeted the Kidneys, with removal of Blood stasis only when and if necessary. Of course, this dovetails neatly with the discovery that some endometriosis lesions contain no extravasated blood at all and that such tissue can produce secretions which clog up the system – Phlegm-Damp we call it in TCM. Treatment which boosts Kidney Yang is generally rather effective at clearing such Phlegm-Damp.

A patient presenting to a TCM clinic with endometriosis will be diagnosed according to her main symptoms and her constitution. When treatment is prescribed as part of an infertility treatment, the doctor will be particularly mindful of reinforcing Kidney Yang and resolving Blood stagnation. Liver Qi stagnation and Spleen Qi deficiency may also contribute and some cases of endometriosis will exhibit elements of Heat or Cold or Damp. To understand the part that Blood stagnation plays it is necessary to explore further our understanding of the way endometriosis is formed and how we relate this to TCM concepts (Fig. 5.1).

Our knowledge about the anatomy and behavior of endometriosis is still limited and so some of these ideas may change or be expanded in the future.

We do know that menstrual blood travels not only downwards from the uterus and out through the cervix but also upwards through the fallopian tubes and out into the peritoneal cavity (retrograde menstruation). This small quantity of blood carries with it bits of discarded endometrium. Women with strong uterine cramps (due to Liver Qi stagnation) are more likely to lose more menstrual flow upwards through the tubes. The blood and the tissue will either be reabsorbed, or will remain and establish itself somewhere in the pelvic cavity. If Kidney Yang is strong, then movement of Qi in the pelvis will mobilize the menstrual debris, which should not be there, and it will be efficiently reabsorbed. A weakness of Kidney Yang, on the other hand, will allow the accumulation of blood and tissue such that it stagnates and creates the basis for Zheng Jia or masses to develop.

The bits of endometriosis tissue which develop in the pelvic cavity will be either non-pigmented (i.e., not bleeding) or pigmented because they contain blood vessels. The non-pigmented lesions can develop into the pigmented ones if they develop the blood vessels and start to bleed during the menstrual phase. The non-pigmented types of endometriosis are associated with infertility for reasons not yet fully understood but possibly because they produce secretions which coat the fimbrial ends of the tubes. The treatment which will most directly address this type of endometriosis is one which will strengthen the Kidney Yang and clear Phlegm-Damp. The development of the non-pigmented types of endometriosis is probably facilitated in Spleen Qi-deficient individuals. In this case, treatment must also address the Spleen Qi to facilitate removal of Damp.

The pigmented endometriosis, containing tissue which responds to the hormonal changes, which makes the uterine lining bleed, is the type more likely to cause pain, especially if it is implanted more deeply than just the surface of the peritoneum. Removal of this type of lesion requires the use of Blood-moving herbs and Kidney Yang tonic herbs. The pigmented lesions, especially under the influence of Qi stagnation, can form substantial Zheng Jia in the form of nodules and masses and scar tissue. In these cases, there may be both pain and infertility: the latter may be absolute if the masses have damaged or obstructed the tubes. Treatment calls for the use of strong Blood-‘breaking’ herbs backed up with Kidney Yang tonics. Table 5.1 charts these relationships.

The skilful approach to treatment is to appropriately target that lesion with unerring aim – whether with a scalpel, laser or acupuncture treatment or strong eliminating herbs to push out or break up obstructions or with gentle herbs to coax hormone levels to balance – and apply these precise arrows in a context of supports: supports for the Kidney Qi, the Spleen Qi, the Liver Qi or whatever it is an individual patient needs. If the ultimate aim is to push the endometriosis to one side to allow pregnancy to occur, then the ovaries, the follicles and eggs and the endometrium must become the central focus of the treatment plan. Maintaining treatment focus on the menstrual cycle at the same time as clearing the endometriosis lesions will bring greater clinical success and increase fertility.

You may remember from Chapter 4, that following and promoting the natural rhythms of the normal menstrual cycle is the basis of all fertility treatments. Thus, Kidney Yin and Blood are nourished in the first part of the cycle after the period and Kidney Yang is supported during the second half of the cycle.

The treatment of endometriosis as a cause of infertility does not differ from this principle but will place emphasis on certain key factors. First, particular emphasis will be placed on building Kidney Yang, since this is one of the causative factors. Strong Kidney Yang tonics will be applied during the luteal phase and the previous (follicular) phase will be primed appropriately to support the growth of Yang. Remember that Kidney Yang is usually built out of a Yin, Blood or Qi base, depending on the body constitution and the pathologic condition of each patient.

Second, if there are signs of stagnant Blood, such as severe period pain with clotty flow, palpable nodules or masses or laparoscopic evidence of bleeding endometriosis tissue in the abdomen, then Blood-regulating treatments will be employed. If treatment is following the natural rhythm of the cycle, then the time to use these herbs is during the period or around ovulation time. Depending on the degree of stagnation, i.e., whether the endometriosis is just small brown dots on the surfaces in the pelvic cavity or whether it is large substantial masses or endometriomas, we will use herbs which gently move the stagnant Blood or herbs which strongly break up Blood stasis (see Table 5.2 and Appendix 2).

Referring to Figure 5.1, you will see there are a number of places where Qi stagnation contributes to the formation of endometriosis. Any prolonged Qi stagnation will of course eventually lead to Blood stagnation because the Qi can no longer lead the Blood adequately. And Liver Qi stagnation, having its roots in emotional stress, is commonly involved. Qi-regulating herbs play an important part in prescriptions which treat endometriosis.

Similarly, Spleen Qi deficiency is frequently a component of Kidney Yang deficiency syndromes. It is the Spleen Qi deficiency which leads to the dragging-down sensation some women experience in the abdomen during the period and may contribute to the heavy bleeding or premenstrual spotting. When Kidney Yang is deficient, and especially when Kidney Yang and Spleen Qi are both deficient, then Damp accumulation will be a problem. Treatment will therefore often include herbs and acupuncture points which clear Phlegm-Damp and invigorate Spleen Qi. Where Damp obstructions persist, Damp-Heat may form, in which case stronger Heat clearing herbs will be necessary.

Whereas TCM treatment follows and corrects any disturbances of the menstrual cycle caused by endometriosis, Western medicine takes the opposite approach. It stops the cycle completely with the use of hormones which trick the body into thinking it is pregnant or menopausal. When the course of treatment is completed, endometriosis is reduced but frequently reoccurs over the next few months. This is because the cause has not been addressed, only the obvious manifestations. The TCM doctor endeavors to locate the original imbalance which allowed the endometriosis to develop in the first place (namely the Kidney Yang deficiency, Spleen Qi deficiency or Liver Qi stagnation) and to treat that, together with the outward manifestations (stagnant Blood, Phlegm-Damp and Damp-Heat); however, that is not to say that the TCM doctor necessarily has greater success than the Western doctor and his drugs. Endometriosis is a difficult disease to treat in any modality, but if the patient is prepared to pursue TCM treatment over 6–12 months the results are generally very encouraging.

TCM treatment of infertility caused by endometriosis begins at the start of a cycle, i.e., it begins with the maturing of a new egg and the growth of new uterine lining as the period is ending, usually around Day 4 of the new cycle. Our aim, of course, is to reduce or clear the manifestations (the endometrial implants and masses) of the disease, the ‘Biao’ in TCM. But this can only be done effectively and completely by treating the ‘Ben’ or the underlying imbalance itself which requires attention to all aspects and functions of the reproductive system during the menstrual cycle. This approach to treatment is especially important if improved fertility is the desired outcome. Treatment of a woman with endometriosis who has no desire to fall pregnant or has already borne children does not need to adhere so strictly to a monthly regimen, although in the opinion of many TCM doctors it is a superior approach.

It is useful to review the guiding formulas and acupuncture protocols for each stage of the cycle, which were presented in Chapter 4:

Herbs and acupuncture points to specifically address the endometriosis can be added at different stages.

Post-menstruation

At this time, our main aim is to build the Blood and reinforce the Yin. Treatment at this time is particularly important for fertility but is not always so important in a woman who is not trying to become pregnant. The protocols suggested for the stages which follow (ovulation and the luteal phases), however, are considered important in the treatment of endometriosis even if pregnancy is not desired.

In the case of severe endometriosis in which the Blood stagnation is pronounced, Blood-regulating herbs can be added at the early phase of the cycle. However, great caution must be applied at this delicate (for the Yin) stage. Unless the woman’s constitution is very strong, there is the risk of damaging Yin with strong Blood movers. Better results are to be obtained by holding them until a later stage of the cycle (i.e., nearer to the period) or until the woman’s constitution can be improved. In many cases, however, some mild Blood-regulating herbs (see below) can be safely introduced. If the case of endometriosis involves the type of lesion that does not cause internal bleeding and the main problem is infertility rather than symptoms of Blood stagnation, then treatment will focus simply on following the Yin and Yang stages of the cycle. No additional Blood-moving herbs above those added routinely at ovulation and period time are required although herbs, which clear Damp may be needed.

Ovulation

If ovulation is associated with pain, as it is in many endometriosis sufferers, then we shall focus more pointedly now on dispelling any Blood stagnation and/or resolving masses if necessary. Caution must still be applied: in less robust women, very strong Blood breakers can upset the sensitive process of switching Yin to Yang, and therefore the process of ovulation itself. Acupuncture can be very helpful in encouraging the movement of Qi and Blood at this time. At the junction of Yin and Yang, attention must be paid to the rise of Yang, and strong Yang tonics must be employed now to ensure its rapid increase if the endometriosis is to be resolved. If Yang does not rise sharply at this point and the Qi and Blood do not move well, then the egg may not be released (as in luteinized unruptured follicle syndromes, or LUFS), or the tube may not successfully capture it or the luteal phase may be inadequate.

You may remember from Chapter 4, that a typical guiding formula to use at this time is the ovulation formula Bu Shen Cu Pai Luan Tang (below) or Wen Yang Hua Yu Fang (below) both of which reinforce Kidney Qi while moving Qi and Blood. When we are treating endometriosis we will add more Blood-moving and Kidney Yang tonic herbs.

If there is severe Blood stasis, then we need to resolve this but in most cases we reserve the Blood-breaking herbs until another time in the cycle if we want to safeguard the Kidney Yin and Yang and potential fertility. Herbs such as San Leng and E Zhu are usually too strong to use at this time unless there are significant and substantial masses or cysts which must be addressed.

Post-ovulation

After ovulation, the aim is to maintain good Yang levels and also to address Spleen Qi deficiency and Damp if that is part of the constitutional picture. Remember that the clinical approach in the second phase of the cycle is to:

These approaches depend on the body constitution and the pathologic condition. In the case of endometriosis, promoting Qi to build Yang is the most commonly used approach.

The Menstrual Period

Where pregnancy is being attempted, treatment to strongly move Blood stagnation must wait until the first signs of a period or the BBT drops (sometimes the temperature drops a day or even two before the period) or there is a confirmed negative pregnancy test. Some tests are sensitive enough to diagnose pregnancy just 10 days after ovulation; these are particularly useful when we want to apply strong Blood-moving treatments before the period but want to exclude a pregnancy first. If there is no pregnancy being attempted (or possible) then herbs or acupuncture points that promote menstrual flow can be commenced well before the period (1 week before). While we used great caution in applying Blood-breaking herbs at other times of the cycle, now we can use them enthusiastically to help remove masses during this phase when endometrial tissue (both inside the uterus and out) is breaking down.

Research and General Comments

Much research is done in China investigating the specific action of herbs on endometriosis – too extensive to describe here in detail but typically they show that treatment with Chinese medicine can help symptoms of endometriosis and reduce blood markers of inflammation. We mentioned a couple of specific observations that have been made on the effect of herbs on follicle and endometrium quality above.

In general, the use of formulas that clear Blood stasis (and modified for each patient) will, over a 3-month period, reduce symptoms and markers of endometriosis, namely, pain relief and reduction of prostaglandin levels and increases in Beta endorphin levels.²⁴

Programs comparing the use of acupuncture and herbal treatment with hormonal treatment for endometriosis have demonstrated superior results for the former in many aspects of clinical presentation and concurrent reduction of prostaglandins PGE2 and PGF2.²⁵

Individual herbs, such as Dang Gui, Bai Shao, Yan Hu Suo, Mo Yao, Ru Xiang, Jiang Huang, E Zhu, Fu Ling, Huang Qin are just some of those that have shown an ability to reduce inflammation and cytokine levels in laboratory and animal studies.²⁶

We said at the beginning of this chapter that endometriosis was a Western medical label and not a Chinese medicine one. Similarly cytokines, inflammation and prostaglandins are Western terms. We cannot see or feel raised levels of cytokines in the follicular fluid, or prostaglandins in the blood, or mucus secreted by endometriotic lesions near the tubes, or disordered implantation sites in the endometrium or inflammation and adhesions in the pelvis but we know that these are all physiologic manifestations of endometriosis. We are also starting to discover through research, that appropriate application of Chinese medicine can change these subtle signs as well as the more obviously assessable ones such as pain and infertility. Thus, even though an endometriosis patient might not manifest strong symptoms or signs of Damp-Heat or Blood stasis, if there is a history of long-term endometriosis (and by the time the patient comes to the acupuncture clinic this is usually the case), then it is appropriate to assume some degree of these pathologic states exist, and you should use herbs or acupuncture points accordingly. However, because treatment of endometriosis is long term, matching the treatment to the patient’s constitution correctly is particularly important. For example, even if a patient has severe widespread endometriosis and adhesions, strong Blood moving treatment cannot be applied long term if she is very Blood and Qi deficient. Similarly, even if we assume there must be significant inflammation in the pelvis, because of the long history and extent of the endometriosis, we cannot just give unmodified and strong Damp-Heat clearing treatment to someone who is very Yang deficient. Rather, addition of herbs which we know can reduce inflammation (or levels of cytokines or prostaglandins), or can break up Blood stagnation can be added at certain times of the cycle in judicious amounts to a larger formula. And at certain times, more single pointed formulas can be given that target the lesion primarily for a short carefully chosen time.

• Damp-Heat

• Stagnation of Qi

• Blood stagnation.

Treating the Biao

Treating the Ben

If the Damp-Heat and pain are not so severe, then it is appropriate to address the underlying condition immediately. This is especially so when we want to recover fertility as quickly as possible.

Abdomen Masses

If there are palpable masses apparent in any of the above types of PID, then the patient is recommended to take appropriate patent medicines along with the main prescription. Because the constitution is weak in the case of chronic PID and the treatment will need to continue a long time, strong Blood-regulating treatment in the form of herbal decoctions is not advisable and most often pill or other preparations, such as the following, will be used:

This formula contains Blood moving and cooling herbs: Mu Dan Pi, Chi Shao and Tao Ren. Gui Zhi is added to assist these herbs in moving Blood and ensures their effect is not too cooling.

Where the stasis of Blood has been very long term, then a stronger formula may need to be employed to break up the congealed Blood. Again, the pill form will be used for long term use as it is less potent than decoction.

This formula contains many strong agents for breaking up long-term Blood stasis (such as Tu Bie Chong, Shui Zi and Meng Chong) and must be used with caution. It cools Heat in the Blood at the same time.

External Treatment

Herbal compresses can also be placed on the abdomen to help ease the pain of PID. The following herbal compress can be used:

This mixture is ground into a powder and put in a bag, which is then steamed for 15 min. The bag is placed on the abdomen and left until it gets cold. This procedure can be repeated two or three times a day. The above amount can be used for 5 days before a new batch needs to be made up.

More formulas for treatment of abdomen masses are described in Volume 3 of the Clinical Handbook of Internal Medicine.²⁹

In the case where discharge and itching of the vulva are associated with PID, then external washes or sitz baths can be helpful. Herbs which remove Damp-Heat and calm inflamed skin are boiled in a large pot of water for half an hour. This liquid is then transferred to a sitz bath. The genital and abdomen area is soaked by sitting in the bath for 15–20 min or while the solution is still hot. The following external wash can be used:

Another approach, which is gaining favor in Chinese hospitals, is the use of herbal enemas in difficult cases of PID. Such an approach has been found to be particularly helpful for abdomen masses and for blockages in the tubes (see Ch. 6).

Dysmenorrhea and PMS

Neither period pain nor premenstrual syndrome are causes or even direct contributing factors to female infertility; however, they can be useful diagnostic components in a clinical picture which includes infertility. That is, they reflect the imbalance which is also the cause of reduced fertility. Most often, they are clear pointers to some stagnation that, in the interests of fertility, must be resolved. Less often, they are pointers to deficiency. Dysmenorrhea and the symptoms of PMS often resolve rapidly when the protocols of Chapter 4 are followed. There may need to be special treatment emphasis on Liver and/or Blood stagnation (or Spleen Qi deficiency) in the luteal phase and Kidney or Blood deficiency in the follicular phase.

• Hypothalamic anovulation

• Hyperprolactinemia

• Premature ovarian failure

• Tumors of the ovary, adrenal or pituitary glands

• Post-oral contraceptive pill amenorrhea

• Polycystic ovary syndrome.

Hypothalamic Anovulation

The hypothalamus fails to give the pituitary the messages necessary for ovulation in circumstances of weight loss, stress, narcotic drug use and extreme exercise like marathon or classical ballet training.

Treatment includes the use of ovulation-inducing drugs (see below) if conception is desired. If pregnancy is not desired, hormones such as those in combined oral contraceptive pills are prescribed to reduce symptoms related to estrogen shortage.

Hyperprolactinemia

High levels of prolactin are produced by the pituitary gland in certain circumstances, causing ovulation to be suppressed. This happens normally in pregnancy to prepare the breasts for lactation and persists while breast-feeding continues. High prolactin levels also occur in abnormal circumstances such as the presence of tumors on the pituitary gland or from the effects of drugs like tranquilizers, heroin, blood pressure medication or drugs for nausea. Treatment of pituitary tumors employs a drug called bromocriptine, which will shrink the tumor and usually allow pituitary function to return to normal.

Where levels of prolactin are elevated only slightly, ovulation may still occur but the corpus luteum function is diminished, causing inadequate progesterone production.

Premature Ovarian Failure (POF) and Resistant Ovary Syndrome

If the menstrual cycle ceases before age 40, it indicates a premature depletion of ovarian follicles. A biopsy taken from the ovary shows few or no follicles. The use of drugs to stimulate ovulation is pointless because there are too few follicles to stimulate. This disorder has a strong genetic component but can also be related to autoimmune conditions or infections or iatrogenic causes. It is sometimes called premature menopause. Women with POF are usually offered the option of donor oocytes should they want to conceive. Another and less common form of ovarian failure is called resistant ovary syndrome. Unlike the previous case, a biopsy of the ovary will reveal plenty of primordial follicles which appear dormant or unstimulated (and are unable to be stimulated by the drugs usually used to induce ovulation). It is thought there may be a receptor block on the surface of the ovary to FSH, or antibodies to FSH or LH that prevent the ovary from responding.

Drug treatment involves giving small amounts of estrogen for 4–6 weeks and at some time during this course progesterone will be added for 2 weeks. A small number of women with resistant ovaries respond to this approach and they will ovulate and conceive.

Tumors in the Ovaries or Adrenal or Pituitary Glands

Tumors in the ovary or adrenal gland, causing a disturbance to ovulation will usually require surgery. Tumors in the pituitary gland are usually discovered when high levels of serum prolactin are investigated, mentioned above.

Post-pill Amenorrhea

In a significant number of women, periods do not return after stopping the oral contraceptive pill. It is thought by gynecologists that one of the above described causes of amenorrhea has developed during the time the pill was being taken and that this is incidental to the effect of the pill. However, some doctors would relate the amenorrhea to the action of the pill (see PCOS, below). Many cases of post-pill amenorrhea resolve by themselves within a year, but where there is evidence of a tumor, medical treatment will be undertaken.

Polycystic Ovary Syndrome (PCOS)

This disorder is an increasingly common cause of amenorrhea or oligomenorrhea. We will discuss this condition later, in another section.

Clomifene

This drug, sold as Clomid or Serophene, blocks the negative feedback action of estrogen, so that the pituitary is tricked into producing a lot of FSH in an attempt to stimulate follicles. Clomifene is cheap and easier to administer than other ovulation-inducing drugs and so is usually the first drug tried. It is given for 5 consecutive days starting between Day 2 and Day 6 of the menstrual cycle. Where there is no menstrual cycle, a period is created by giving a course of a progestogen. The starting dose of clomifene is 50 mg/day, though this can be raised progressively in subsequent cycles to as much as 200 mg/day if necessary. If the action of the clomifene is successful, it will induce ovulation 9–15 days after the first day it is taken. Most patients ovulate in response to 50 or 100 mg/day and, if conception occurs, it will likely be in the first three ovulatory cycles.

Side-effects are common, especially at the higher doses. They are:

From the fertility point of view, the useful stimulation of the follicles that the clomifene achieves is undone to some extent by the deleterious effect it has on the fertile mucus (which is dried up) and the endometrium (which becomes too thin). These unwanted side-effects mean that only 50% of patients who do ovulate successfully with clomifene will become pregnant, even with its continued use. Since some of these side-effects (like the thinning of the endometrium) appear to get worse with repeated clomifene cycles, it is not advisable to continue the drug for more than three cycles at a time. In addition, 20% of pregnancies achieved with the use of clomifene will miscarry, a high rate that may also be due to inadequate development of the endometrium or poor embryo quality.

FSH Preparations

The other way to induce ovulation is to bypass the pituitary gland and stimulate the ovaries directly using FSH. The drug form of FSH (Gonal-F, Puregon, Follistim) is a synthesized molecule using recombinant gene technology. It is given by subcutaneous injection every day for around 2 weeks. Once several follicles reach a mature size (around 2 cm diameter), then the FSH stimulation is stopped to allow all but one or two to undergo atresia (die) before a trigger injection is given to make the follicle release its egg. Intrauterine insemination (IUI) is often performed shortly after this.

If many eggs are desired for use in an IVF procedure (see Ch. 10), then larger doses of FSH are continued right up to the trigger injection and egg collection.

Because this treatment acts so directly on the follicles in the ovary, there is little in the way of natural feedback controls or brakes in the process and ultrasounds and blood tests must be used to monitor the response of the ovaries.

Treatment with FSH, while it can have side-effects, is successful in inducing ovulation in more than 90% of the cycles in which it is used. However, the viable pregnancy rate is only 5–25% per cycle, depending on the reason for the ovulatory disturbance in the first place. Miscarriage occurs in 12–30% of these pregnancies, a higher than normal rate, which may reflect defects of the luteal phase or the quality of the embryo.

hCG Preparations

Pregnyl, Novarel, and Profasi are preparations of human chorionic gonadotrophin (hCG) isolated from the urine of pregnant women. Ovidrel is a genetically manufactured product that is identical to the body’s hCG. These drugs do not stimulate follicle development but induce ovulation of follicles which have already been stimulated by other drugs. hCG preparations have a physiologic action similar to LH, i.e., they prepare the eggs and the follicles which encase them for ovulation. These drugs are used in IUI and IVF treatment cycles.

Bromocriptine

Bromocriptine (Parlodel) is given for the disorder hyperprolactinemia. It mimics the action of dopamine, the natural inhibitor of prolactin production, and thereby lowers prolactin levels to normal so ovulation can occur. The drug can cause side-effects in the beginning and if these continue it is given as a vaginal pessary rather than an oral medication to minimize its effect on the liver. Ovulation and conception usually occur soon after the administration of bromocriptine unless there are other factors influencing fertility.

Metformin

Metformin (Glucophage, Diaformin, Diabex) is used in the treatment of type 2 diabetes to control blood sugar levels. Such control of blood sugar has proved to be useful in women with polycystic ovary syndrome (PCOS), especially if they are overweight. Ovulation tends to occur more frequently in women with PCOS if they take metformin.

Clomifene

TCM affords us an interesting perspective on drugs like clomifene – by examining and analyzing the effects it can have we can determine its action in an energetic sense. Clomifene is considered a ‘heating’ drug and it has been observed to be effective in increasing fertility in cases where there is Kidney Yang deficiency. However, infertility related to Kidney Yang deficiency often develops from or is accompanied by Kidney Yin deficiency. When there is pronounced Yin deficiency and internal Heat, then taking something as heating and drying as clomifene presents more of a risk. From the Chinese medicine point of view, the Yin damaging effects of the drug – namely, the hot flushes, the drying up of the fertile mucus, the thinning of the endometrium and the irritability – are quite worrying. In sensitive individuals, the Liver and Kidney Yin, which are so vital for fertility, can be damaged. At best, in such cases, it produces uncomfortable side-effects and at worst, it damages the ovaries so that they stop functioning altogether.

On the other hand, in a Yang-deficient woman, perhaps with Phlegm-Damp accumulation, its heating and drying effect can be most beneficial.

FSH Preparations

If we analyze what symptoms occur when these IVF drugs (Gonal-F, Follistim, Puregon) are used, we can see that the main side-effect is stagnation of the Liver Qi. Usually this is not severe; symptoms include abdomen swelling and tenderness, breast soreness and a feeling of irritability or emotional volatility.

hCG Preparations

The ovulation trigger – hCG (Pregnyl, Novarel, Profasi) – in assisted reproduction or IVF cycles is added to mimic the action of LH in releasing the egg from the follicle. This is the equivalent of adding a sudden dose of a Yang influence to switch the artificially manipulated cycle from its Yin phase to its Yang phase. At this point, pre-existing Qi stagnation can be greatly compounded. A worst case scenario sees the precipitation of a condition called ovarian hyperstimulation syndrome or OHSS (discussed in Ch. 9), which in its more severe manifestations is associated with abdomen pain and swelling, nausea, dizziness, headaches, and ascites, which are all signs of increasingly significant Liver Qi stagnation. This can further develop into Blood stagnation, resulting in embolism or into Liver Wind, causing stroke or fitting, both potentially life-threatening situations.

Bromocriptine

Once again the side-effects of Parlodel (bromocriptine) tell us which organ system it affects. If too much is given too quickly, then headaches, nausea, and dizziness can develop, indicating that the Liver Qi is disordered.

Metformin

This drug can damage Spleen function, causing diarrhea, bloating, flatulence and nausea in susceptible women. The concurrent use of Spleen tonic formulas can increase tolerance to the drug; however, where any digestive symptoms persist, then it is not advisable to continue the medication.

Knowing how a particular drug affects the balance of the body in an energetic sense gives the TCM doctor a good understanding of whether it is an appropriate drug treatment for any given patient. For example, women who are already quite Yin deficient with internal Heat must use clomifene with great caution. Likewise, women with a tendency to Liver Qi stagnation must be monitored even more carefully than usual if they are administered ovulation-inducing drugs such as Gonal-F, Follistim, Puregon with hCG triggers. Women with Spleen weakness may need to find alternatives to taking metformin.

Kidney Jing Deficiency Amenorrhea

Kidney Jing or essence deficiency represents a congenital cause of primary amenorrhea, whereby the Tian Gui does not arrive and the Chong and the Ren vessels never function.

Kidney Jing deficiency can also contribute to secondary amenorrhea where, although there may be some Chong and Ren vessel foundation laid, the periods stop. Because the Jing is weak, an important component in the production of Blood from marrow is lacking. Thus there is insufficient Blood to fill the Chong vessel and menstruation ceases. The contribution of the Kidney Jing in the production of Blood is more important than the role of the Spleen and Stomach when we are considering this type of amenorrhea.

If periods never begin (primary amenorrhea) we would say that Kidney Jing is deficient and the Tian Gui never arrived. Other types of amenorrhea such as resistant ovary syndrome and some cases of premature menopause or primary ovulatory failure can also be related to Kidney Jing deficiency, especially if they occur at a young age. The problem in primary ovulatory failure and very premature menopause lies within the ovary itself, i.e., primordial follicles are not present, or what little was there has been depleted. In resistant ovary syndrome there are plenty of primordial follicles but they are resistant to the stimulation that normally turns them into functional follicles which produce ripe eggs. In the Chinese medicine view the Jing is deficient and the action of the Tian Gui is lacking. This is the reason so few women with resistant ovary syndrome have success with hormonal treatment. In these women, a very basic aspect of the Kidney Jing is lacking and the first stages of follicle growth and egg maturation are faulty, i.e., the Tian Gui is not functioning.

Treatment of severe Kidney Jing deficiency is unlikely to be successful. Even the amenorrhea resulting from the less severe forms of Kidney Jing deficiency are difficult to treat successfully although an attempt is worthwhile. To treat this condition, formulas which build Kidney Yin and Yang are often modified with the addition of animal products.

Kidney Yin Deficiency Amenorrhea

This is the most common cause of amenorrhea (not related to PCOS). The Yin becomes deficient due to lifestyle factors or a constitutional tendency (see Ch. 2). Yin, as we know, is required for the eggs to ripen, the production of fertile mucus and to provide the precursor to making Blood in order to thicken and nourish the endometrium. Deficient Kidney Yin symptoms include infrequent or no periods, no fertile mucus, dizziness and lower back pain.

Where Yin deficiency gives rise to Heat, Heart- and Liver-Fire can develop. Both will exacerbate the Yin deficiency and compound the amenorrhea in their own way. Heart- and Liver-Fire, which can cause agitation, irritability and insomnia, can also dry the Blood so the endometrium cannot develop. Dryness also leads to constipation and thirst. Many cases of premature menopause fall into this category and it is the aggressive clearing of Heat which, if there are any follicles left, allows the ovary to function again, for a short time at least.

Another more rare expression of Heat from Yin deficiency is sometimes seen in cases of amenorrhea, and this is Kidney-Fire. This occurs in severe amenorrhea when the Yin and Blood are exhausted (possibly after postpartum hemorrhage or long-term illness). It is very difficult to recover the Yin at this point.

Kidney Yin deficiency will, with time, eventually lead to Kidney Yang weakness, since the two are so interdependent. Then there may be lassitude, vertigo, palpitations, blurred vision, lower back pain and edema accompanying the amenorrhea. This can represent an advanced condition which also can be difficult to treat successfully.

In addition to premature ovarian failure or menopause, Kidney Yin deficiency amenorrhea includes hypothalamic anovulation, (often provoked by weight loss or long-term illness) and some variations of polycystic ovary disease.

Treatment of Kidney Yin amenorrhea is little different from the treatment we described in Chapter 4, addressing Kidney Yin deficiency infertility. The only difference is that we don’t have a menstrual cycle to follow and so we attempt to create one.

Our first aim is to reinforce the Yin and nourish the Blood using, e.g., the same guiding formula we used in the post-menstrual phase when treating infertility: namely, Gui Shao Di Huang Tang. Where there is no menstrual cycle at all, this formula (or variations of it) will be used in the long term with the addition every 3 or 4 weeks of a group of herbs which boost the Kidney Yang and encourage movement of the Blood. Thus, we attempt to lay a foundation of Yin and Blood, then promote the transformation of Yin to Yang followed by movement of the Blood downwards. If there is no period after 2 or so weeks of taking the Kidney Yang and Blood-regulating herbs, then go back to the base formula for another 2 or 3 weeks before adding Yang tonics and Blood-moving herbs again. Treatment can continue like this for some months before any result is seen if the Yin deficiency is severe.

Blood Deficiency Amenorrhea

When Blood deficiency causes ovulatory disturbance it is usually associated with Kidney Yin (and sometimes Kidney Jing) deficiency. In some cases, amenorrhea follows loss of large amounts of blood after hemorrhage (e.g., after termination of pregnancy, miscarriage or childbirth) or is a result of a severely compromised Spleen function. Such damage may occur to the Spleen if there is undue physical strain, e.g., young women training intensively in sport, long periods of overwork and/or under-nutrition, or after long-term illness.

Treatment principally focuses on diet, with an emphasis on iron-rich and other Blood-building foods (discussed in Ch. 12). A sensible balance between rest and exertion is advised. There are no absolutes here: it depends very much on the individual constitution. However, if it is lifestyle that has contributed to the loss of periods, then the inappropriate behavior must be rectified.