ANTA PROFESSIONAL SEMINAR Achieving healthy MOTHERHOOD with Chinese Herbal Medicine
FERTILITY
FERTILITY Normal fertility depends upon the following factors: The integrity of the female and male reproductive tracts The release of a normal oocyte The production and release of adequate spermatozoa The normal transport of the gametes to the ampullary portion of the fallopian tubes for fertilization The subsequent transport of the cleaving embryo to the endometrial cavity for normal implantation and further development.
FERTILITY
INFERTILITY Definition: Failure to conceive after one year (used to be 2 years) of sexual activity without contraception, even though both parties are healthy. ~ 80% of couples attempting to conceive are successful after six months; ~ 90% after 1 year; and ~ 95% after 2 years. Currently, about 17% of couples in developed countries seek medical advice for infertility. Due to later childbearing in Western countries and impatience, women often come for assistance after 6 months ( only ~ 50% infertile or subfertile). ~ 50% of women with difficulty conceiving have nothing wrong ( treat for stress)
CAUSES Female factors: 46-58% (possibly less) Male factors: 18-25% (possibly more) Male and female combined: 18.5% Unknown etiology: 10-25% ( often go on to conceive) Other causes: 5% FEMALE INFERTILITY Common known causes Pelvic inflammatory disease (PID) Endometriosis Environmental and occupational factors (exposure to poisons, oestrogenic chemicals, etc.) Toxic effects related to tobacco, marijuana, or other drugs Exercise (too much or too little) Inadequate diet associated with extreme weight loss or gain Advanced age
MAJOR KNOWN CAUSES of FEMALE INFERTILITY Ovulatory failure (mostly due to hormonal factors) Tubal damage Endometriosis Medical drugs, e.g. non steroidal antiinflammatory (NSAIDS)
CURRENT MEDICAL TREATMENTS Ovulatory failure: Clomifene IVF Metformin Tubal damage: IVF (possibly also: tubal flushing with oil soluble media; tubal surgery before IVF) Endometriosis: Intrauterine insemination (IUI) plus gonadotrophins. Laparoscopic ablation of endometrial deposists IVF
MEDICAL TREATMENT OUTCOMES IVF: 21.8% live birth rate per treatment cycle. If the woman s age is less than 38 years this is increased to 25.1%. After five attempts, approximately 50% of women under 34 years will have conceived. (Cost = approx. $4,000 per cycle) Tubal surgery: 5% - 50% depending on the extent of tubal damage. Clomiphene citrate: With the achievement of 3 consecutive ovulatory cycles, 40-50% of women will become pregnant.
TCM TREATMENT RESEARCH Dharmananda, S. (1996). Chinese Herbs And Fertility. From ITM Online, Articles. (Chinese studies conducted up to 1996) clinical studies conducted in China indicate that about 70% of all cases of infertility (male and female) treated by Chinese herbs resulted in pregnancy or restored fertility. Depending on the particular study and the types of infertility treated, success rates ranged from about 50% up to more than 90%.
TCM TREATMENT RESEARCH Yu, J. (1998). Obstetrics and Gynecology in Chinese Medicine An Integrated approach. Seattle, WA: Eastland Press In experimental animals and in vitro, herbs which tonify the Kidneys can increase LH secretions and can increase the progesterone contents in the corpus luteum of pseudo pregnant rats. (Yu, 1998, p.75 (i.e. herbal treatments that tonify the Kidney normal growth of secretory endometrium in luteal phase and in pregnancy)
TCM TREATMENT RESEARCH Huang, S., Chen, A. (2008). Traditional Chinese medicine and infertility. Curr Opin Obstet Gynecol; 20(3):211-5 Recent studies demonstrated that traditional Chinese medicine could regulate the gonadotropin-releasing hormone to induce ovulation and improve the uterus blood flow and menstrual changes of endometrium. In addition, it also has impacts on patients with infertility resulting from polycystic ovarian syndrome, anxiety, stress and immunological disorders. (i.e. promote normal, healthy functions and also restore fertility)
SYSTEMATIC REVIEWS OF TCM Tan, L., Tong, Y.,Sze, S., Xu, M., Shi, Y., Song, X., Zhang, T. (2012). Chinese herbal medicine for infertility with anovulation: a systematic review. J Altern Complemen Med; 18(12):1087-10 CHM significantly increased the pregnancy rate and reduced the miscarriage rate compared to clomiphene. CHM also increased the ovulation rate and improved the cervical mucus score compared to clomiphene. CHM is effective in treating infertility with anovulation. Also, no significant adverse effects were identified for the use of CHM
SYSTEMATIC REVIEWS OF TCM Ried, K., Stuart, K. (2011). Efficacy of Traditional Chinese Herbal Medicine in the management of female infertility: a systematic review. Complement Ther Med; 19(6):319-31 Meta-analysis of RCTs suggested a 3.5 greater likelihood of achieving a pregnancy with CHM therapy over a 4-month period compared with WM drug therapy alone Meta-analysis of selected cohort studies (n = 616 women) suggested a mean clinical pregnancy rate of 50% using CHM compared with IVF (30%)
CHINESE HERBAL MEDICINE IS MORE EFFECTIVE
TCM APPROACH According to the Huang Di Nei Jing ( Yellow Emperor s Classic of Medicine, circa 1 st Century BCE): In general the reproductive physiology of woman is such that at seven years of age her Kidney energy becomes full, her permanent teeth come in and her hair grows long. At fourteen years the tian gui (or fertility essence ) matures and the chong and ren channels responsible for conception open, menstruation begins and conception is possible.. At forty nine years the chong and ren channels are completely empty, and the tian gui has dried up. Hence the flow of the menses ceases and the woman is no longer able to conceive. (Ni, 1995, p. 2)
HUANG DI NEI JING
THE KIDNEY IN TCM
THE KIDNEY IN TCM The Kidney stores Essence and therefore controls growth, development and reproduction The Kidney produces the bone marrow, fills the brain, and controls the bones The Kidney governs fluid metabolism The Kidney receives and absorbs the Qi from the Lung The Kidney Yin and Yang are the basis of the Yin and Yang of all the other organs The Kidney governs the Fire of the Life Gate The ears are the signaling sense organ of the Kidney The genitals, urethra and anus are controlled by the Kidney The Kidney houses the zhi (will, determination, concentration and memory) The condition of the Kidney is manifest in the hair on the head Mucoid saliva is the fluid secretion that relates to the Kidney
THE KIDNEY ESSENCE Kidney Essence (KE) is a very broad concept that includes a variety of complex phenomena. There are two aspects: reproductive Essence (RE) and the nutritive Essence (NE). RE: tissues and fluid secretions that are involved in human reproduction; controls sexual maturation, fertility and the capacity to reproduce. NE: controls the whole life cycle: growth and development, maturation, decline and senescence. KE is continually being used up and requires constant replenishment, which is provided by the activities of the Spleen. The Kidney s capacity to store Essence steadily declines with age; this is part of the reason for the decline in function that occurs with normal ageing. Chronic illness, overindulgence in sex, immoderate use of alcohol and recreational drugs may cause a more rapid loss of Essence.
KIDNEY ESSENCE DEFICIENCY Sexual hypofunction (infertility, loss of libido and impotence) Early ageing: premature graying of the hair, hair loss, loose teeth Dizziness or vertigo, tinnitus, poor memory, sleep disturbance, hearing loss Pain and weakness of the low back and knees Emaciation Severe fatigue Tongue is red and peeled (if with Kidney Yin deficiency) or pale and swollen (if with Kidney Yang deficiency) Pulse is weak and rapid (Kidney Yin deficiency predominant) or deep, weak and possibly also slow (Kidney Yang deficiency predominant)
DIFFERENTIAL DIAGNOSIS Two major categories of infertility/subfertility: Hormonal Structural (i.e. obstructive) Basic differentiation in TCM: Deficiency syndromes ( hormonal) Excess syndromes ( structural / obstructive)
DIFFERENTIAL DIAGNOSIS Deficiency: Kidney Essence deficiency Qi-Blood dual deficiency Excess: Qi stagnation and Blood stasis Phlegm-Damp retention
CLINICAL SYNDROMES Kidney Essence deficiency (deficiency) Qi-Blood dual deficiency (deficiency) Qi stagnation and Blood stasis (excess) Phlegm-Damp retention (excess) Clinically these syndrome patterns generally occur in combinations (i.e. women usually present with mixed deficiency and excess patterns) True infertility or subfertility generally involves at least some degree of Kidney Essence deficiency (may be less than 50% of women presenting in clinic)
KIDNEY YANG-ESSENCE DEFICIENCY Long menstrual cycle, possibly amenorrhea Either excessive watery discharge or dry vagina Loose stools Cold signs: intolerance of cold, cold extremities and lower abdomen Urination is copious and clear Tongue is pale swollen and moist Pulse is deep, weak and slow
KIDNEY YANG-ESSENCE TREATMENT DEFICIENCY Classical formulas: You Gui Wan (Right Returning Formula), Ba Ji Yin Yang Wan (Morinda Formula), Qi Bao Mei Ran Dan (Polygonum & Cuscuta F.) Commonly used herbs: Yin yang huo (epimedium), rou cong rong (cistanche), tu si zi (cuscuta), du zhong (eucommia), ba ji tian (morinda) Modern empirical formulas: MOTHERHOOD 2 FORMULA (CM184) plus HAIR GROWTH FORMULA (CM136) Variants: With irregular periods: + BLOOD MOVING 2 FORMULA (CM191)
KIDNEY YIN-ESSENCE DEFICIENCY Early menstruation (i.e. short cycle) Dry mouth Night sweating Red tongue with little or no coat Pulse is rapid
KIDNEY YIN-ESSENCE DEFICIENCY Generally occurs in combination with other syndromepatterns Add one of the following to the appropriate protocol Classical formulas: Zuo Gui Wan (Left Returning Formula), Si Wu Wan (Dang-gui Four), Ba Ji Yin Yang Wan (Morinda Formula), Qi Bao Mei Ran Dan (Polygonum & Cuscuta F.) Commonly used herbs: Shu di huang (rehmannia), gou qi zi (lycium fruit), nu zhen zi (ligustrum), han lian cao (eclipta), shan yu rou (cornus fruit) Modern empirical formulas: + YIN TONIC FORMULA (CM118) Or + HAIR GROWTH FORMULA (CM136)
QI AND BLOOD STAGNATION Irregular cycles, infrequent periods Dysmenorrhea, PMS Menstrual flow is dark and contains dark clots Dark or purple tongue or tongue with dark or purple spots
QI AND BLOOD STAGNATION This is the most common clinical presentation Generally also with deficiency (Kidney and Qi-Blood) Classical formulas: Tao Hong Si Wu Wan (Persica, Carthamus & Dang-gui C.), Chai Hu Shu Gan Wan (Bupleurum & Cyperus C.), Zi Shen Yu Tai Wan (Dang-gui & Epimedium F.) Commonly used herbs: Dan shen (salvia), chi shao (red peony), tao ren (persica), hong hua (carthamus), yu jin (curcuma), wu yao (lindera), xiang fu (cyperus) Modern empirical formulas: MOTHERHOOD FT-1 FORMULA (CM140) Plus HAIR GROWTH FORMULA (CM136)
QI AND BLOOD DEFICIENCY Long cycle or amenorrhea Scanty menstrual flow, which is pale in colour Pale or sallow complexion Fatigue, muscular weakness Poor appetite, (loose stools) Palpitations, postural dizziness, (cold extremities, tingling or numbness of the extremities) Tongue is pale with a thin white coat Pulse is thready and weak
QI AND BLOOD DEFICIENCY Classical formulas: Ba Zhen Wan (Ginseng & Dang-gui Eight), Shi Quan Da Bu Wan (Ginseng & Dang-gui Ten), Qi Bao Mei Ran Dan (Polygonum & Cuscuta F.) Commonly used herbs: Ren shen (ginseng), dang shen (codonopsis), bai zhu (atractylodes), huang qi (astragalus), dang gui (angelica tang-kuei), bai shao (peony), he shou wu (polygonum/fallopia). Modern empirical formulas: MOTHERHOOD FORMULA (CM162) Plus HAIR GROWTH FORMULA (CM136)
PHLEGM-DAMP RETENTION Overweight or obesity Prolonged menstrual cycle with scanty flow or amenorrhea Leucorrhea (thick discharge) Pale complexion Dizziness Palpitations, full sensation in the chest Nausea Tongue coast is greasy (white or creamy-yellow) Pulse is slippery
PHLEGM-DAMP RETENTION Common presentation with tubal blockage, ovarian cysts or PCOS Classical formulas: Nei Xiao Luo Li Wan (Prunella & Scrophularia F.), Gui Zhi Fu Ling Wan (Cinnamon & Hoelen C.), Wen Dan Tang (Bamboo & Hoelen F.), Long Dan Xie Gan Tang (Gentiana F.) Commonly used herbs: Ban xia (pinellia), zhu ru (phyllostachys nigra), chen pi (citrus peel), zhi shi (citrus fruit), fu ling (poria), dan nan xing (arisaema) Modern empirical formulas: Add one of these classical formulas to one of the above protocols, as appropriate.
DURATION OF TREATMENT Generally it takes 3 4 cycles to restore normal functioning (less for younger, more for older women). Following this it is best to allow another 3 4 cycles to consolidate the treatment and strengthen the constitution. Women with more severe pathology (e.g. endometriosis, PCOS, scarring from prolonged PID) and older age group may need up to 12 months of treatment. Once pregnant treatment should be stopped.
Appendix 1 MALE INFERTILITY Most common cause is deficiency of the Liver (Blood) and Kidney (Essence) Other causes include Damp-Heat (= chronic low grade infection); and Blood stasis (history of trauma or effects of chronic infection) Note: protocols for Damp-Heat and Blood stasis are not provided. Modern empirical formulas: SEXUAL FUNCTION FORMULA (CM112) Plus + HAIR GROWTH FORMULA (CM136) Variations: With loss of libido: + MENS FORMULA (CM160)
Appendix 2 CARE DURING MORNING SICKNESS PREGNANCY Classical formulas: Wen Dan Tang, Xiang Sha Liu Jun Zi Tang, Ginger tea (use fresh ginger) Modern Formulas: CLEAR THE PHLEGM FORMULA (CM180) Or DIGESTIVE TONIC FORMULA (CM155) with poor appetite
CARE DURING PREGNANCY THREATENED MISCARRIAGE Classical formulas: Shou Tai Wan, Tai Yuan Yin Commonly used herbs: Tu si zi (cuscuta seed), xu duan (dipsacus), sang ji sheng (loranthus), e jiao (donkey hide gelatin), huang qi (astragalus), ren shen (ginseng) dang shen (codonopsis), bai zhu (atractylodes), zhu ma gen (boehmeria) Modern empirical formulas: MOTHERHOOD FT-2 FORMULA (CM138)
CARE DURING PREGNANCY FATIGUE Classical formulas: Bu Zhong Yi Qi Tang, Si Jun Zi Tang, Shi Quan Da Bu Wan. Modern empirical formulas: MOTHERHOOD FT-2 FORMULA (CM138)
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