Chinese Medicine Gynecology & Obstetrics

Transcription

1 The Journal of Chinese Medicine Gynecology & Obstetrics Quarterly Issue from The Canadian Gynecology Institute of Chinese Medicine Winter, 2011 In this issue ء An in depth look at menstrual physiology ء Clinical uses of Xiao Yao San ء Experience based infertility treatments ء Treatment for simple obesity

2 The Journal of Chinese Medicine Gynecology & Obstetrics Presented by: The Canadian Gynecology Institute of Chinese Medicine 1128 Eglinton Ave. W. Toronto, Ontario M6C 3J6 Phone: Or: Editors: Yuxiang Wang, Caroline Prodoehl Copyright 2011 The Journal of Chinese Medicine Gynecology & Obstetrics. All rights reserved in all countries. Contents may not be reproduced in any manner without written permission of the editor. The journal serves as a forum for writers and the views expressed are not those of the publisher or The Canadian Gynecology Institute of Chinese Medicine. The material printed herein is intended for educational purposes only and no responsibility is assumed for misadventure resulting from maltreatment or misdiagnosis. If you have a health problem, you should consult a qualified practitioner. Self medication is dangerous and inefficient. Medical knowledge is constantly changing. As new information becomes available, changes in treatment, procedures, equipment and the use of drugs become necessary. The authors and the publishers have taken care to ensure that the information given in this text is accurate and up to date. However, readers are strongly advised to confirm that the information, especially with regard to drug usage, complies with the latest legislation and standards of practice. Contents 1 The Interaction between Kidney Qi, Tiangui and the Chong Meridian in Menstrual Physiology ~Yuxiang Wang 4 Xiao Yao San Clinical Use Applications ~Cao Weiping 6 The Study of Female Infertility on Syndrome Treatment ~Meng Wei 9 Exploring Dr. Han Bing s Experiences with Infertility: Tonify the Kidney & Regulate Chong Treatment ~Qin Shu Fang 13 Acupuncture Treatment for Perimenopausal Syndrome ~Yuxiang Wang 17 Perimenopausal Syndrome: Chinese Herbal Treatment ~Yuxiang Wang 21 Pivot Theory, A Case Study: Exploring the Etiology, Pathology & Treatment of Menopausal Syndrome ~Cong Huifang 24 Research & Acupuncture Treatment for Simple Obesity ~Zhongchen Zhang - 2 -

3 The Interaction between Kidney Qi, Tiangui, and the Chong Meridian in Menstrual Physiology Abstract Yuxiang Wang President of the Canadian Gynecology Institute of Chinese Medicine This paper is a study on the theory of menstrual physiology in Chinese medicine. The author advances the theory that menstrual physiology relies on the Qihua (Qi activity for the transformation of material) of Kidney which is based on the interaction between Kidney-Qi, Tiangui, and the Tai-Chong meridian (the leg branch of the Chong meridian). In brief, Tiangui is one component of primordial Qi in the Life Gate, and it goes to the uterus through the Chong and Kidney meridians. Both the Chong meridian (Tai-Chong vessel) and Kidney meridian share the same pathway, so when the Chong Qi in the Tai-Chong vessel (supplied by Tiangui) goes downwards through the Kidney meridian, the Qi in Kidney meridian moves upwards. This opposing movement of Qi creates the force for the Blood and Qi to penetrate into the muscles and collaterals. Also, the Kidney coordinates with the Heart, Liver, Spleen and Lung, so Blood and Qi in the Chong meridian nourish the viscera interiorly and muscles and joints exteriorly. The upward, downward, inward and outward circulation of Blood and Qi are what results in the regular period bleeding and the storing and eliminating function of Kidney. Clinically, it is important to regulate Qi movement when treating gynecological diseases. When there is a deficiency of Chong-Qi, Kidney Qi should also be strengthened and the Liver should be regulated, especially when there is abnormal Qi movement in cases of Chong Qi excess syndromes. Key Words: Kidney Qi, Tian Gui, Chong meridian, Tai Chong meridian, Ren meridian, menstrual physiology, Qi Hua, menopause, premenstrual syndrome, theory, Liver Qi, excess, deficiency, reversed flow, treatment, herbs, acupuncture, moxibustion Herbal Formulas: Chai Hu Shu Gan San, Long Dan Xie Gan Tang, Wen Dan Tang, Xiao Chai Hu Tang, Xiao Yao San, Yi Guan Jian, Zhen Gan Xi Feng Tang Analysis Huang Di Nei Jing is the earliest text in Chinese medicine that describes human sexual development. It pointed out that at age seven, girls start to develop permanent teeth and their Kidney Qi starts to mature. Menstruation occurs at age of 14 with the appearance of Tiangui and the flourishing flow of Qi and Blood in the Ren and Chong meridians. In later texts, many medical men have advanced the theory about the Kidney, Tiangui, and Chong and Ren meridians, but much information is still lacking on their interactions. This theory is important for the study and clinical treatment of gynecology and menstrual physiology in Chinese medicine. It is imperative to explore the interaction between the Kidney, Tiangui and Chong meridian. Qihua (Qi activity) of Kidney and Menstrual Physiology As stated earlier, there are three key factors in menstrual formation: the growing of Kidney Qi, the arrival of Tiangui, and the flourishing flow of Qi-Blood in Chong and Ren meridians. The prerequisite is the maturation of Kidney Qi which therefore plays the most important role on the formation of the menstruation. Zhang Jing Yue, who wrote the Complete Works of Jing Yue, stated menses are the extra part of blood, ultimately implying that menses originate from the blood. All kinds of material transformations that happen through life rely on the function of Qihua of the Kidney. Transformation from blood into menses occurs under the power of Qihua upon maturation of the Kidney Qi which initiates the production of Tiangui. Tiangui is the component of Kidney Qi which mainly focuses on sexual function. The Nature of Tiangui and its role on the Qihua of Kidney In Chinese, Tiangui or Tiangui Zhi has two meanings. Firstly, Tiangui is the growing from feebleness to prosperity ( Zhi meaning strength or prosperity ). Secondly, it denotes the transportation of Tiangui to the uterus after being produced by the Kidney ( Zhi also means arriving ). These two meanings are complementary for the reason that only prosperous Tiangui is able to be transported to the uterus

4 The nature of Tiangui has been a topic of dispute from ancient times to present times. During the Ming dynasty, Ma Shi stated that Tiangui is innate Kidney Yin-essence (Yuan Yin); Zhang Jing Yue held that Tiangui is one component of primordial Qi (Yuan Qi); while the author of the book Yi Zong Jin Jian (Golden Mirror of Medicine) described Tiangui as the active Qi between both Kidneys. Although these views of Tiangui differ, they have the same basic perspective about the nature of Tiangui. Yuan Yin and Yuan Qi are the same concept within two aspects. Yuan Yin is the substance for Yuan Qi; Yuan Qi is the manifestation of Yuan Yin. Yuan Qi is stored in the Life Gate (Ming Men), which is located between both Kidneys. This has led to the wide belief that Tiangui is the active Qi between both Kidneys. With regards to the relationship between Tiangui and Yuan Qi of the Life Gate, predecessors recognized that Yuan Qi of the Life Gate plays some role in reproductive function; the book Classic on Medical Problems (Nan Jing) says: Ming Men (Life Gate) has the function of storing sperm for men and being in charge of the pregnancy process for women. But no predecessors have clarified the relationship between Tiangui and Yuan Qi. After studying the function of Tiangui and Yuan Qi of the Life Gate, it has been deduced that they are same substance: Yuan Qi contains Tiangui and is encompassing concept; Tiangui is only a part of Yuan Qi which is transported to the uterus and has its function with menstrual formation and pregnancy. How does Tiangui get to uterus? The answer can be found in the Qing dynasty book: Essence of Medical Classic in the Confluence of Chinese and Western Medicine, written by Tang Zong Hai, who stated: Tiangui travels to uterus through the Kidney meridian. As stated earlier, the transformation of blood into menses relies on the Qihua of Kidney; Tiangui in the uterus responds to this transformation of blood to menses. Tang Zong Hai wrote: Blood from meridians of Chong and Ren arrive in the uterus, interact with Tiangui and are transformed to menses. The role of the Chong Meridian in Menstrual Formation and how the Tai-Chong Meridian is Impacted by Kidney Qi and Tiangui From meridian theory we know that the Chong meridian originates from the uterus and it has three major branches. One branch travels upwards along the spine, another branch goes up the foot-yang Ming Stomach meridian, and the third goes inside of Foot-Shao Yin Kidney meridian. It is the Sea of Blood and its functions are to nourish the viscera and muscles and send its extra blood down to the uterus to transform into menses. The term Tai-Chong is mentioned in the Nei Jing, but there are very few other doctors that discuss what exactly this meridian is. According to Wang Bing, the first scholar to study the Nei Jing, the Tai-Chong meridian travels down the Kidney meridian opposite in direction to the flow of Kidney Qi, which flows up from the foot to the chest. Therefore, Tai-Chong is regarded as the most prosperous branch of the Chong meridian because it is supplemented by both Tiangui and Kidney Qi. Since the Chong meridian originates from uterus, uterine Tiangui not only transforms blood to menses through the Qihua function of the Kidney, but also warms and nourishes the muscles and joints to keep them strong and flexible. This is achieved through the opposing movements of the Chong Qi traveling down to the feet and the Kidney Qi going upwards to the uterus and beyond which powerfully forces the Qi and Blood to go to the collaterals. This explains why patients with menstruation problems often manifest with signs and symptoms such as cold feet and swollen ankles: the Chong Qi is unable to go downward to warm and nourish the muscles and joints. There is also strong evidence that shows the connection between Tiangui, Chong Qi and the lower leg muscle in the menopause stage. After menopause, Tiangui has dried up, and with declining Chong Qi, menses will cease and the leg and foot muscles can start to atrophy and the joints can become stiff. Interaction of the Kidney with other Viscera in Menstrual Physiology The Nei Jing said: Kidneys regulate water and menses through their function of both storing and eliminating. Menses are the manifestation of the eliminating function of Kidney, and after menses, the Kidneys store the Blood-Essences until next menses. Menstruation demands that the Qihua function of the Kidney coordinate with the other viscera: the Heart, Liver, Lung, and Spleen must coordinate in a dynamic synergy. Interaction of the Kidney and Heart: the Heart connects to the Uterus through collaterals and the Kidney connects to the uterus through the Chong channel. The Qihua function of the Kidney relies on the upward movement of Kidney Qi in conjunction with the downward movement of Heart Qi. This harmony of movement is a prerequisite for maintaining normal menstrual physiology. If the Heart Qi is unable to travel - 2 -

5 to Uterus, the Kidney Qi will be unable to eliminate and amenorrhea will occur. If excessive fire of the Heart disturbs the Uterus, the Kidney will eliminate excessively and heavy menstruation will occur. Interaction of Kidney and Liver: Liver has the function of maintaining the free flow of Qi. Therefore, movement of Kidney Qi and Heart Qi relies heavily on the Liver s function of free flow. Liver Qi goes down to the Uterus via the Chong channel where it distributes the Blood for transformation into menses Blood. Liver Qi stagnation or overacting Liver Qi will affect the harmony of Qi movement and cause a dysfunction with how the Kidney stores and eliminates, either resulting in amenorrhea, irregular menstrual cycle or dysfunctional uterine bleeding. Interaction of Kidney and Spleen: Spleen Qi is ascending in nature and Stomach Qi is descending in nature, thus this action is known as the pivot of Qi movement. A Spleen deficiency will cause dampness to accumulate, which will ultimately affect the movement of Kidney Qi, Heart Qi and Liver Qi, causing menstrual problems. A Theoretical Guide to Menstrual Physiology in Clinical Practice The most important treatment method in the gynecology practice is to Regulate Qi. It is the theoretical basis for any gynecological treatment method. My teacher, Dr. Ha LiTian, one of the most famous TCM gynecologists in China in last century, often told me his experience has been that regulating Qi when making prescriptions is the key for ideal effectiveness. In the pathology of gynecology, the abnormal movement of Qi is the leading mechanism which causes dysfunctional menstruation, leucorrhea, pregnancy problems, and postpartum diseases. Dr. Ha was very good with his use of regulating Qi herbs in his prescriptions for treating gynecological diseases. He often used herbs like Xiang Fu (nutgrass flatsedge rhizome) to activate Qi movement and influence the Blood, and Chuan Xiong (chuanxiong rhizome) to activate the blood in order to harmonize Qi. In acupuncture treatment, Taichong (LV-3) is a very useful point to regulate Qi to treat many gynecological diseases because the point has the function of regulating Chong Qi. Tonifying the Kidney to treat Deficiency of Chong Qi In pathology of gynecology, impairment of Chong and Ren is the final cause of all gynecological problems. Diseases are classified into deficiency syndromes and excess syndromes. In deficiency syndromes, Chong and Ren deficiency are the most closely related with Kidney deficiency. As we have previously discussed, Chong Qi originates from Tiangui which is produced by the Kidneys; it is a part of primordial Qi (Yuan Qi), and transports to the uterus through the Kidney channel, so tonifying the Kidney is the best way to boost Chong Qi in the treatment of gynecological diseases related to deficiency of Chong Qi. In clinic, we use herbs to tonify Kidney Qi, nourish Kidney Yin and Warming Kidney Yang in order to replenish Chong Qi. The Following herbs are most often used: Tu Si Zi (dodder seed), Xian Ling Pi (epimedium), Xian Mao (curculigo rhizome), Ba Ji Tian (morinda root), Du Zhong (eucommia bark), Lu Jiao Jiao (antler fule), Rong Cong Rong (desertliving cistanche), Gou Qi Zi (wolfberry fruit), He Shou Wu (fleece-flower root), Dang Gui (Chinese angelica root), Shao Yao (peony root), Shu Di (prepared rehmannia root), Gui Ban (tortoise plastron), Sang Ji Sheng (loranthus mulberry mistletoe), Xu Duan (dipsacus root), Fu Pen Zi (Raspberry),etc. Acupuncture treatment for deficient gynecological diseases, according to the principle of tonifying Kidney to replenish Chong Qi, use Shenshu (UB-23), Qixue (KI-13), Taixi (KI-3), Sanyinjiao (SP-6), GuanYuan (RN-4) are often selected. Smooth Liver Qi to Treat Excess of Chong Qi due to Reversed Flow Qihua of Kidney relies on the normal movement of Qi for menstrual formation, especially the balance between Kidney Qi move upward and Heart Qi move downward to the Uterus. The Liver has the function of maintaining free flow of Qi movement which assist in maintain the harmony between Kidney and Heart, which in turn, keeps the function of the Chong and Ren meridians normal. When Liver Qi fails to maintain free flow of Qi movement, reversed flow of Chong Qi occurs. Many gynecological diseases are pathologically related to the reversed flow of Chong Qi such as irregular menstruation, dysmenorrhea, premenstrual syndrome, morning sickness, eclampsia, leucorrhea, pruritus vulvae, infertility, invasion of the blood chamber by heat, gynecological masses, etc. In clinic, smoothing Liver Qi is the effective way to harmony Chong Qi. There are several treatment methods for smoothing Liver Qi according to the different kinds of Liver dysfunction. The following are most common: 1. Regulate Qi to smooth Liver Qi, represented by: Chai Hu Shu Gan San

6 2. Lower upward adverse Qi to smooth Liver Qi, represented by: Wen Dan Tang. 3. Calm down Liver Yang to smooth Liver Qi, represented by: Zhen Gan Xi Feng Tang. 4. Clear away Liver to dispel fire, represented by: Long Dan Xie Gan Tang. 5. Regulate Shao Yang to smooth Liver Qi, represented by: Xiao Chai Hu Tang. 6. Nourish Liver Yin to smooth Liver Qi, represented by Yi Guan Jian. 7. Harmonize Liver and Spleen, represented by: Xiao Yao San. In acupuncture, Sanyinjiao (SP-6) is the most useful point in gynecology which has the function of smoothing Liver Qi, another two points to regulate Chong Qi are Neiguan (PC-6) and Gongsun (SP-4). Xiao Yao San Clinical Use Applications Cao Weiping Shandong University, Traditional Chinese Medicine Teaching Hospital Originally published in the 4 th Conference of Gynecology Committee of the World Federation of Chinese Medicine Society. This version has been translated by Yuxiang Wang and Caroline Prodoehl. Abstract Xiao Yao San was originally described in the classic Tai Pin Hui Min He Ji Ju Fang Prescription of Peaceful Benevolent Dispensary, and is still widely used in clinics today. The eight ingredients include Chai Hu, Dang Gui, Fu Ling, Bai Shao, Bai Zhu, Bo He, Gan Cao, and Sheng Jiang. Its function is to regulate Liver Qi, nourish Blood and strengthen the Spleen and is thus used for Liver Qi stagnation, Blood deficiency and Spleen deficiency syndrome. Commonly used modifications include Dan Zhi Xiao Yao San, which adds Mu Dan Pi and Zhi Zi to clear Heat; Hei Xiao Yao San which adds Sheng Di for Blood deficiency causing Liver Qi stagnation with Heat; and Xin Zhi Xiao Yao San which adds Xi Xin and Bai Zhi for the syndrome accompanied by dampness. These treat many different types of diseases and in this article the author exemplifies some of its uses. Key Words: Xiao Yao San, Liver Qi stagnation, Spleen deficiency, Blood deficiency, perimenopause syndrome, breast distention, menses, periods, menstruation, melasma, shingles Herbal Formulas: Xiao Yao San, Er Zhi Wan, Dan Zhi Xiao Yao San Analysis Perimenopause Syndrome Upon coming into the clinic for the first time in October, 2010, Ms. Fang was 49 years old. She complained of having irregular periods for one year with profuse and lengthened periods. This was accompanied by insomnia and dreaminess, depression and worry, hot flashes, sweating, vertigo, dry throat, red tongue with a thin white coating and a wiry rapid pulse. Treatment: Xiao Yao San + Er Zhi Wan: Chai Hu 15g, Bai Shao 12g, Bai Zhu 12g, Dang Gui 9g, Niu Zhen Zi 15g, Han Lian Cao 15g, Sheng Di 20g, Mai Dong 15g, Fu Xiao Mai 30g, Suan Zao Ren 30g, Zhi Mu 9g. 3 packages for 3 days: Ms. Fang s mood is happier and sleep has improved Continued formula for 20 doses and all symptoms were relieved Discussion: According to Nei Jing, when women reach 49 years of age, Ren Mai becomes deficient, Chong Mai is depleted and Tian Gui dries up. Since Ms. Fang is at the age of her menopausal transition time, her Kidney Qi is declining, Chong-Ren are deficient and deficiency of Kidney Yin produces internal Heat, which is combined with Liver Blood deficiency resulting in the Liver not dispersing Qi and causing - 4 -

7 her symptoms. So Xiao Yao San is used to regulate Liver Qi and Er Zhi Wan is used to nourish Yin and clear deficient Heat. Sheng Di and Mai Men Dong are the modifications used to astringe and nourish Yin; Zhi Mu is used to clear deficient Heat; Fu Xiao Mai is used to astringe sweating and Suan Zao Ren is used to help sleep. This formula had good results. Breast Distention around Periods Ms. Chen, 38 years old, first came to the clinic in October, 2010 complaining of breast distention starting one week before her period and resolving upon initiation of menses. Unsmooth flow of bleeding with dark colour of blood, low abdominal distention, hypochondriac pain and distention, depressed mood, frequent sighing, a thin white tongue coating and a wiry and slippery pulse are also present. On palpation, breast glands are tender and in the upper left quadrant of the left breast there are 1.5cm x 1.5cm nodules. Diagnosis: Liver Qi Stagnation with Phlegm Accumulation Treatment: modified Xiao Yao San: Chai Hu 15g, Fu Ling 15g, Bai Zhu 15g, Bo He 9g (added at the end), Bai Shao 15g, Dang Gui 12g, Xia Ku Cao 15g, Xiang Fu 15g, Wang Bu Liu Xing 9g, Yuan Shen 30g. 1 dose per day, 42 doses. After completion symptoms were relieved and nodes had disappeared. Discussion: According to Chinese Medicine, the nipple is related to the Liver and the breast is related to the Stomach. Ms. Chen has underlying Liver Qi Stagnation, so when the Blood descends to the Chong and Ren before and during her period it causes Liver Blood deficiency which becomes more apparent with the resulting hyperactivity of Qi, especially Chong Qi. The hyperactive Qi follows the Liver Meridian up and causes the Liver Qi and Blood to stagnate and block in the breast, which causes the distention in that area around the time of her period. Xiao Yao San was used as a treatment along with Xiang Fu to regulate Qi and activate Blood; and Yuan Shen, Xia Ku Cao, and Wang Bu Liu Xin to dissipate masses. Together, the work to regulate Qi, activate Blood and relieve pain. Melasma Ms. Xin, 32 years old came to the clinic on December 2 nd, 2010 complaining of melasma at the malar region of the face for one year with the size gradually expanding. The colour is dark brown along with a dusty and diminished complexion. She is also irritable and easily gets angry, her period has clots, her tongue has purplish spots and her pulse is uneven and thready. Treatment: Regulate Liver Qi, activate Blood circulation, remove melasma. Formula: modified Xiao Yao San: Chai Hu 15g, Xiang Fu 15g, Bai Shao 9g, Dang Gui 15g, Fu Ling 15g, Yu Jin 12g, Tao Ren 9g, Hong Hua 9g, Chuan Xiong 12g, Bai Zhi 12g, Bo He 6g (cooked later). After 9 doses, the colour was already lighter After 20 more doses the colour became continually lighter Patent formula of Xiao Yao San was used for another 2 months. After 2 months the patient called and reported that the colour was almost all gone Discussion: The Liver is very important for women. Liver Qi stagnation and Blood stasis will affect the face and cause melasma. In the formula, Chai Hu and Xiang Fu were used to regulate Liver Qi, and Bo He guides the herbs to the face. This formula had very good results. Shingles On February 18, 2011, Ms. Pan, 52 years old came in complaining of burning pain around the right hypochondriac region for 3 days. In the last day, herpes blisters have appeared that are the size of a soy bean with clear liquid inside and a red border, and have distributed in a belt-like fashion. Accompanying signs include difficulty sleeping, irritability, dry moth, bitter taste in the mouth, a red tongue with a thin yellow coating, and a wiry-thready pulse. Formula: modified. Dan Zhi Xiao Yao San: Dan Pi 12g, Zhi Zi 12g, Chai Hu 12g, Fu Ling 20g, Bai Zhu 12g, Bo He 9g (cooked later), Sheng Di 30g, Yuan Hu Suo 12g, Chuan Lian Zi 9g, Ju Hua 9g, Long Dan Cao 9g

8 3 doses were given along with antiviral medications and vitamins 2 nd Visit: February 22, 2011, pain is reduced, sleep is better, same formula continued 3 rd Visit: 7 days later, rash has dried and there are scabs, but no redness or swelling, some parts have a light brown colour. Discussion: This type of shingles is related to Liver Qi stagnation and Spleen Qi deficiency with Damp toxins affecting the skin. The Liver Qi stagnation produces stagnant Fire which affected the Spleen. The Dampness and Heat produced by the malfunctioning of the Liver and Spleen along with the Dampness and Heat toxins invading are what caused the disease. Dan Zhi Xiao Yao San was used to clear the Liver Heat and Fire, strengthen the Spleen and eliminate the Dampness. Yan Hu Suo and Chuan Lian Zi were added to regulate Qi and relieve pain; Ju Hua for clearing Liver Heat; Long Dan Cao for clearing Liver and Gallbladder Damp Heat; and Sheng Di to cools and nourish the Blood. The formula was used for about 10 days and in that time the disease was totally cured. Summary In Chinese Medicine, the Liver stores the Blood, likes free flowing and dislikes depression. The Liver Meridian is distributed along the hypochondriac region, goes behind the throat, connects with the eyes and meets with the Du Meridian at the vertex of the head. If Liver Qi stagnates, this can affect the movement of Qi and Blood in all 5 Zang-Fu organs and cause many different types of diseases. In the formula Xiao Yao San, Chai Hu regulates Liver Qi and removes stagnation; Bai Shao nourishes both the Liver and the Blood and gathers Yin with its sour, bitter and cool natures; Dang Gui, being sweet, pungent, bitter and warm in nature, nourishes the Blood and regulates the Qi; Bo He disperses stagnant Qi and stagnant Liver Heat; and Sheng Jiang is used to harmonize and regulate the other herbs as well as disperse stagnation with its pungent taste. All of the cases in this article use a modified version of Xiao Yao San. Even if the diseases are different they all belong to the same syndrome: all are related to Liver Qi depression along with Qi stagnation, Heat or Blood stasis. The treatment was to smooth the Liver Qi flow and through modification treat the individual cases. This exemplifies how one treatment principle in Chinese Medicine can treat different diseases, all belonging to the same syndrome, with the same treatment. The Study of Female Infertility on Syndrome Treatment Meng Wei Chinese Medicine Hospital of Hong Kong University Originally published in the 4 th Conference of Gynecology Committee of the World Federation of Chinese Medicine Society. This version has been translated by Yuxiang Wang and Caroline Prodoehl. Abstract Fertility Requirements In Huang Di Nei Jing it stated that for conception to occur, there are certain requirements, namely strong Kidney Qi, the arrival of Tian Gui, regular periods, Chong and Ren are open and flourishing, and Yin- Yang connection (intercourse). The international standards define infertility as the inability to become pregnant, while not using birth control, after 1 year of intercourse. This is compared with Traditional Chinese Medicine (TCM), which defines infertility as the inability to conceive a child after two years of intercourse without the use of birth control

9 Recent treatments that have increased the chances of conception include in vitro fertilization (IVF), with the first birth being March 10, 1988 and gamete intra-fallopian transfer (GIFT), with the first child born on October 18 th of the same year. Since then, the treatments have been further refined and have shown increasing rates of conception and fetal stability. IVF technology has made it possible for 30-40% of infertile patients to conceive. This technology has made the impossible possible. Even still, IVF has its fair share of problems that need to be resolved, including the risk of multiple pregnancies, overstimulation syndrome, the high cost related with the procedure, and the relatively low rate of success. For these reasons, doctors and researchers need to continue to work diligently on improving infertility treatments. Key Words: fertility, infertility, difficult conception, unqualified ovum disorders, menses, periods, menstruation, cycles, medications, Human Chorionic Gonadotropin, HGC, Luteinizing Hormone, LH, Human Menopausal Gonadotropins, hmg Analysis Difficult Conception due to Unqualified Ovum Disorders The main cause of infertility is irregular menstrual cycles. In the normal menstrual cycle, a quality follicle and egg are produced and conception will occur. In other words, for a quality egg to be produced, a regular menstrual cycle is necessary. In clinics, basal body temperature (BBT) is used to evaluate the staging of menstrual cycles, though with new and improved technologies ultrasound and blood work are now used more often. Reasons for Irregular Menstrual Cycles: a normal menstrual cycle shows normal function of Qi, Blood, Zang-Fu and meridians. Previous gynecologists focused on the menstrual cycle as it is a manifestation of the proper functioning of the internal workings of the body, especially related to fertility. A typical menstrual cycle is 28 to 30 days and the body temperature is biphasic, elevating on day 14 to day 15. If the menstrual cycle is irregular, it is difficult to produce a quality egg. Thus, the regularity of the cycle determines the quality of the egg. It is important to note, however, that it is not only the current cycle that determines egg quality; the regularity of the previous cycles also play a role in the quality of the current egg. If a menstrual cycle is irregular, it will affect follicle and egg development, ovulation, and luteinizing function for approximately two future cycles. It is the endocrine system that causes menstrual cycle irregularities, though the exact mechanism is not well understood since there are many factors or even medical reasons that influence the proper functioning of the endocrine system, including infertility treatment drugs. Thus, it is important to know how infertility drugs work and how they cause irregular periods in order to use these medications appropriately. Medications that cause Irregular Cycles Human Chorionic Gonadrodropin, better known as HCG is a popular and very useful hormonal medication used for infertility. Generally, HCG has three functions: a) to stimulate ovulation, b) aid in luteinization, and c) to maintain pregnancy. In the normal endocrine system, luteinizing hormone (LH) has the function of stimulating ovulation, though LH is difficult to synthesize so instead HCG is used. Both hormones have a similar mechanism and function, though they have differing degrees of producing effective results. HCG is stronger, more effective, and lasts longer and is therefore more useful for maintaining pregnancy. With LH the effective time is measurably shorter. Therefore clinics typically use HCG to induce ovulation since the effects are stronger and longer lasting. The benefits of using HCG are also its greatest pitfalls. First, the increased effectiveness and longevity causes a reduction in the woman s own production of LH and luteinization which reduces the hormone levels for future menstrual cycles. Secondly, when HCG was used in the clinic, during the second menstrual cycle, it was found that the follicles had enlarged and estrogen was secreted within the ovaries. This enlargement caused an atretic follicle (premature degeneration of the follicle), making it unviable. Also, since these enlarged follicles - 7 -

10 produced estrogen, a small cyst often developed in the ovary. This manifestation was seen not only through clinical observation but also through measured changes using an electron microscope. This basically denotes that with each cycle in which HCG is used, there is an increased chance of developing follicle atresia compared to women who do not use HCG, making it difficult to produce quality eggs and a further difficulty of having adequate luteinization. This is compounded by the development of small ovarian cysts which produce estrogen, affecting the first half of the menstrual cycle the follicular phase. To summarize, in the follicular phase the follicle is developing but is enlarged, and the increase in estrogen due to the cysts will shorten this phase, resulting in irregular periods. The second half of the cycle, the luteal phase, is also affected and a decrease in luteinization occurs, shown in the BBT chart and again, resulting in irregular menstrual cycles. The irregular menstrual cycles due to HCG s effect on both the follicular phase and the luteal phase exacerbates any infertile condition. Human Menopausal Gonadotropins, or hmg is used if a patient urgently wants to conceive. If the woman already has irregular menstrual cycles, this will result in the production of immature and unviable, often mutated eggs. Though, if the woman first takes the time to regulate her periods until she has two normal cycles and then uses hmg to stimulate the ovaries, the follicles are able to mature and several may be present. Based on the study of these hormones, certain conclusions can be inferred: 1. Having normal menstrual cycles is not the only requirement of fertility. 2. Irregular cycles can cause immature follicles 3. Fertility medications should be used with caution with women who have irregular periods 4. The primary treatment for infertility should be to regulate menstrual cycles for which Chinese Medicine is an excellent treatment option. Recognition of Infertility in Chinese Medicine In the Huang Di Nei Jing, the Yellow Emperor s Canon, the Du Meridian is part of the reproductive system. Hence, if the Du Meridian has illness, infertility can occur in women. Jing Gui Yao Lue, the Essential Prescriptions of the Golden Coffer, writes that in men if the pulse is superficial, floating, weaker and uneven, this can cause infertility related to sperm dilution due to Kidney Yang deficiency. West Jin dynasty s Zhen Jiu Jia Yi Jing, the A-B Classic of Acupuncture and Moxibustion was the first classic to relate infertility to stagnant Blood in the uterus and the use of Ren-4. Zhu Bing Yuan Hou, the General Treatise on the Causes and Symptoms of Disease describes the reason of infertility as related to disease. This disease is the impairment of Qi and Blood, the abnormal invasion of Wind and Cold attacking the uterus causing sickness in the uterus and resulting in irregular periods, leucorrhea and infertility, or the imbalance of Yin-Yang leading to irregular periods. Here, the treatment principle should be to regulate the menstrual cycle. During the Ming Dynasty, Jing Yue Quang Shu, the Complete Works of Zhang Jing Yue, writes that the blood is very important for women as it can transform into Essence, and with enough Essence pregnancy can occur. Thus, it is important to check the Blood and this can be done by looking at the menstrual cycle. In women s diseases, the Blood should be regulated. The treatment should focus on tonifying the Ming Men Gate, tonifying Qi, and nourishing Blood to regulate the menses to achieve fertilization. This classic also explains the physiology, pathology and mechanism of infertility and also stresses the importance of regulating the menses and tonifying the Ming Men in order to facilitate conception. This relates to the treatment principles used now of tonifying the Kidney and regulating the Chong and Ren Meridians. The etiology and pathology of infertility is very complicated. There are both male and female factors to consider. Women can have Kidney deficiency, Blood deficiency, Cold in the uterus, Liver Qi stagnation, Phlegm and Dampness obstructing, pathological changes in the Ren and Du Channels, Blood stasis, etc. According to the Nei Jing, for women if the Kidney Qi is strong, the Tian Gui arrives, the Ren and Chong are open and flourishing and Yin and Yang are connected, then conception can occur. If the Ren and Tai Chong Meridians are declining, Tian Gui is exhausted, and if the fluids in the Meridians are exhausted, and the body becomes old then infertility occurs. This means that the strength of the Kidney Qi is of the utmost importance since the Kidney Qi is the original Qi and the root of the Ren and Chong Meridians. The Chong Meridian is the Sea of Blood and the Ren is the Conception Vessel and together these Meridians replenish each other in order to facilitate conception. Thus, if there is a Kidney-Chong-Ren Meridian dysfunction, infertility occurs and since the Zang-Fu and Meridians are also closely related to the Kidney, Chong and Ren, other manifestations can occur as well. In clinic, often seen diseases include - 8 -

11 Liver Qi stagnation, Blood deficiency, Phlegm obstruction and Blood stasis, which can all cause dysfunction of the Kidney, Chong and Ren, leading to infertility. Meanwhile, in western medicine, female infertility factors can be caused by fallopian tube disorders, ovulatory disorders, uterine factors, cervical factors, vaginal factors, chromosomal mutations or abnormalities, genetic factors, or immunological factors. Exploring Dr Han Bing s Experiences with Infertility: Tonify Kidney & Regulate Chong Method of Treatment Qin Shu Fang #2 Teaching Hospital of Tianjing Hospital of Traditional Chinese Medicine Originally published in the 4 th Conference of Gynecology Committee of the World Federation of Chinese Medicine Society. This version has been translated by Yuxiang Wang and Caroline Prodoehl. Abstract Dr. Han Bing is chairman of the Gynecology Committee and a famous Traditional Chinese Medicine (TCM) gynecologist with over 50 years of experience in the field. His expertise is using 8 Extra Meridian Theory (Qi Jing Ba Mai) to treat difficult gynecology cases. He believes that in chronic and difficult to cure cases, the 8 Extra Meridian Theory should be used to differentiate and locate the area of disease. Tonifying the Kidney and regulating the Chong and Ren Meridians are the most important methods to use when treating difficult gynecology cases. Key Words: Dr. Han Bing, fertility, infertility, tonify Kidney, regulate Chong, gynecology, theory, Xu Lingtai, Fu Jingzhu, Zhang Xicun, dysmenorrhea, leucorrhea, treatment, case study Herbal Formulas: Wen Qi Hua Shi Tang, Yi Huang Tang Analysis Tonify the Kidney, Regulate Chong & Ren: Theory Foundation In the field of gynecology, the function of the Chong and Ren Meridians are the most applicable of the Meridians in the 8 Meridian Theory. In the Nei Jing, it stated at 7 years, a woman s Kidney is strong and the baby teeth change to permanent teeth and the hair grows. At 14 years, Tian Gui arrives, the Ren Meridian opens and the Chong meridian flourishes, her period comes regularly and she is able to become pregnant.. At 49 years old, the Ren Meridian is deficient, the Tai Chong meridian is depleted, Tian Gui dries up, Meridian fluids are exhausted, the woman s body gets old and she can no longer become pregnant. This passage describes the opening and flourishing of the Ren and Chong and the process of the reproductive system from development and growth to pregnancy and aging. In the Sui Bing Dynasty book, Zhu Bing Yuan Hou Zong Lun General Treatise on the Causes and Symptoms of Disease, the etiology and pathology of gynecology are discussed within its eight volumes. It held that the Chong and Ren Meridian functions are related with menstruation, vaginal discharge, pregnancy, postpartum, breast feeding and other types of physiological phenomenon. When pathologies occur, especially when factors such as Wind-Cold attack the uterus and impair the Chong and Ren, irregular periods can occur; cold attacking the Chong and Ren results in amenorrhea; and bleeding problems are also related to the Chong and Ren along with a Qi Deficiency that leads to the inability to hold the Blood. Understanding the pathological changes related to the Chong and Ren is the foundation for understanding how to treat gynecological disorders

12 The first book on the topic of gynecology, the Fu Ren Da Quan Lian Fang - The Complete Effective Prescriptions for Women, the author postulates 36 types of women s disease that are all related to Chong and Ren impairment. The Chong and Ren both originate from the uterus and are collectively known as the Sea of Meridians. When the Blood in the Chong and Ren go up, there will be breast milk and when the Blood in the Chong and Ren go down, there will be menstrual blood. Both the breast milk and menstrual blood are transformed in the Chong and Ren and a dysfunctional Chong and Ren results in a deficiency of milk causing the baby to have weakness and illness. Ye Tianshi also focuses treatment on the 8 Extra Meridians, especially the Chong and Ren in his book Lin Zheng Zhi Nan Yi An - A Guide to Clinical Practice with Medical Records. A few key points are brought forth in this text: the Chong for men can store the Essence, while for women it holds the uterus. Here also, infertility and irregular periods are related to Chong and Ren Meridian disease. Too many labors and too many pregnancies can cause a deficiency of the Chong and Ren Meridians; lochia and leucorrhea after labor is related to a deficiency of the Chong and Ren Meridians. Treatment should focus on regulating and tonifying the Chong and Ren Meridians as well as treating the other 6 Extra Meridians. During the Qing Dynasty, a few famous doctors further developed theories around the 8 Extra Meridians, namely Xu Lingtai, Fu Jingzhu, and Zhang Xicun. Dr. Xu thought the Chong and Ren were the most important Meridians for pregnancy and menstruation. He stated that if one can understand Chong and Ren physiology and pathology, one can understand all gynecological problems. In treatment, Dr. Xu stated that since all menstrual irregularities and leucorrhea are related to the Chong and Ren, one should treat the Chong and Ren Meridians, and especially focus on nourishing Blood. For this reason, ancient formulas all use Blood nourishing herbs in treatment. Fu Jingzhu, in his book Gynecology of Fu Jingzhu mentions various diseases due to imbalances of the Chong and Ren Meridians. He stated metrorrhagia is due to Blood heat the Chong Meridian is the Sea of Blood and if the Meridian is cold, this will cause emptiness in the Blood Sea, while if there is too much heat, the Blood will boil. Metrorrhagia is related to too much heat in the Chong Meridian. Dr. Fu also discusses dysmenorrhea, stating that both the Chong and Ren are located in the Lower Jiao; the Chong is the Sea of Blood and the Ren is the Conception Vessel responsible for pregnancy. If there is Cold-Damp blocking the Chong and Ren, this will disturb the two Meridians and cause pain. Treatment focuses on removing Dampness and warming the uterus to harmonize the Chong and Ren Meridians and relieve pain. The formula Wen Qi Hua Shi Tang (Warm Umbilicus to Remove Dampness Decoction) is used. Bai Zhu is the main herb and regulates Qi around the lower back and umbilicus; Ba Ji Tian and Bai Guo open the Ren Meridian; and together Bian Dou, Shan Yao and Lian Zi protect the Chong Meridian. In the discussion of this formula Dr. Fu explains that the Qi of the Chong and Ren prefer free flowing, not descending and therefore one should not use Cang Zhu or Yi Yi Ren to dissolve the Dampness. In relation to yellow leucorrhea, Dr. Fu argued that the disease is related to Damp Heat in the Ren Meridian. He argued that some people believe that Damp Heat in the Spleen is related to the yellow discharge and that the treatment should be to treat the Spleen, but this is wrong. One should tonify the Ren Meridian and clear the Heat in the Kidney. Thus, use Yi Huang Tang (Remove Yellow Discharge Decoction). In this formula, Shan Yao and Qian Shi are used to tonify Ren to treat Ren deficiency as well as regulate water; Bai Guo is used as a guide to direct herbs to the Ren Meridian, and Huang Bai clears the Heat in the Kidney. Since the Kidney and Ren Meridian are connected and replenish each other, clearing the Heat in the Kidney will also clear the Heat in the Ren Meridian. Dr. Fu s theories on the relationships between the 8 Extra Meridians in gynecology have been a great influence for later doctors. To summarize, menstruation is a physiological phenomena which is related to the Zang-Fu, Qi-Xue, and Jing-Luo all working together in harmony in the uterus. The Kidney Qi, Tian Gui and Chong-Ren Meridians are the key factors. Only if the Kidney Qi is strong, the Tian Gui arrives, the Chong-Ren are open and flourishing, and the Essence and Blood flow into the uterus can menstruation and pregnancy occur. The Kidney is the base of the axis on which these physiological functions are formed. It is the prerequisite for female development and maintenance of reproductive function; the Kidney stores the congenital essence, including Yin and Yang. In the Nei Jing it stated that the Kidney stores the Essence and therefore the strength of the Kidney decides the arrival, maturation or exhaustion of Tian Gui, and if the Chong Meridians are open and flourishing. Therefore the Kidney is the organ most related to reproduction

13 The Kidney Yin and Yang are the material and power for a woman s reproductive development and must remain harmonized and flourishing in order to maintain normal physiological functioning. If Kidney Yin or Yang is deficient, or if there is Yin deficiency with Yang hyperactivity, there will be an inability to maintain normal functioning and Tian Gui and Chong-Ren will become dysfunctional and result in gynecological problems. Therefore, the Kidney, Chong and Ren are central to the proper functioning of a woman s reproductive system. Their function needs to be well coordinated to ensure capability, arrival and completion of menstruation and pregnancy. The Kidney, at the highest level, controls all of these functions. Through Tian Gui, the Kidney regulates the Chong and Ren Meridians at the lowest level; meaning, the Chong and Ren are the target meridians for the Kidney. Based on the above theories, Prof. Han Bing uses the tonify Kidney and regulate Chong Meridian method to treat abnormal gynecological functioning. Through regulating the Chong meridian, by default Qi is also regulated and harmonized, and in Chinese Medicine theory, harmonizing is crucial. Since the Kidney is the root of Zang-Fu function and all other organs are nourished by the Kidney Yin and warmed by the Kidney Yang, by tonifying the Kidney all other organs will be regulated as well, especially the Liver. The Liver and Kidney have the same source: the Liver stores the Blood and the Kidney stores the Essence, and Essence and Blood can transform into each other. Also, by regulating Chong, the Qi can flow freely, a function which is related to Liver. Thus, through the Kidney, the Qi and the Blood can be harmonized, menstruation becomes regular and pregnancy comes easily. For this reason, Prof. Han Bing always uses the tonify Kidney and regulate Chong Meridian method in the infertility clinic and achieves good results. Tonify the Kidney, Regulate Chong & Ren: Infertility Treatment Application Tonify the Kidney and regulate Chong is the leading treatment principle when treating gynecology disease. This includes diseases ranging from menstrual problems to pregnancy and postpartum disorders, all of which are related to Kidney disease and Chong-Ren irregularities. Herbs used to tonify the Kidney and replenishing Essence often used include: Tu Si Zi, Fu Pen Zi, She Chuan Zi, Lu Jiao Shuang, Ba Ji Tian, Rou Cong Rong, Shu Di Huang, Du Zhong, Zi He che, etc. To regulate the Chong, herbs such as Dan Shen, Wang Bu Liu Xing, Yi Mu Cao, Ji Xue Teng, Dang Gui, Zao Jiao Ci, Lu Lu Tong and Niu Xi are often chosen. Put together in a formula, Tu Si Zi nourishes Kidney Yin, tonifies Kidney Yang, and replenishes Kidney Essence; Fu Pen Zi warms and tonifies the Life Gate; She Chuang Zi tonifies the Kidney; Zi He Che relates to Blood and flesh; Ba Ji Tian and Rou Cong Rong warm and tonify the Life Gate and replenish Kidney Essence; Dan Shen and Yi Mu Cao regulate the Chong and Ren and remove Blood stasis by activating Blood circulation; Ji Xue Teng nourishes the Blood and regulates menstruation. Together, these herbs work together to tonify the Kidney and regulate Chong. For scanty menses with hypochondriac distention and pain due to Liver Qi stagnation, modify by adding Chai Hu, Lu Lu Tong, Ju He, and Yue Ji Hua. Add Gui Zhi, Xi Xin, Ru Xiang and Mo Yao for dysmenorrhea. Pu Huang and Da Huang Tan can be added for heavy menses with blood clots. Heavy menses with low back and knee pain can be treated by adding Sheng Di Huang, Di Gu Pi, Nu Zhen Zi and Han Lian Cao. For low back and knee soreness with aversion to cold, add Zi Shi Ying, Xian Ling Pi, Bu Gu Zhi and Niu Xi. Case Study 1 Ms. Qi, female, 31 years old, first visited on December 7 th, Her chief complaint was infertility for six years. Ms. Qi s periods started at 13 years old, her cycle is a 6/30 day cycle. The blood is bright red in colour with clots. Associated symptoms include lower back soreness, lower abdominal pain, aversion to cold and constipation. Her last period started on December 2 nd, and she still had her period on the first visit. Her tongue is dark red with a thin white coating and her pulse is deep and thready. Basal body temperature is biphasic, her ultrasound results were normal and the partner s semen analysis was also normal. Diagnosis: Infertility due to Kidney deficiency and Chong-Ren Disharmony Treatment Principle: tonify Kidney, regulate Chong and Ren Formula: Dan Shen 30g, Chi Shao 10g, Ji Xue Teng 30g, Gui Zhi 10g, Fu Ling 15g, Wu Yao 20g, Gan Jiang 6g, Ru Xiang 6g, Mo Yao 6g, Rou Cong Rong 15g, Ba Ji Tian 10g, Zi Shi Ying 30g, Ju He 20g

14 At the time of the second visit, Ms. Qi s period had finished and her low back pain had improved. Since she was close to ovulation another formula was used: Formula: Chai Hu 10g, Dang Gui 10g, Chuan Xiong 10g, Lu Lu Tong 10g, Dan Shen 30g, Ji Xue Teng 30g, Ba Ji Tian 10g, Zi Shi Ying 30g, Bu Gu Zhi 10g, Ju He 20g, Niu Xi 10g, Gan Cao 6g. Directions: take 10 packages for 10 days. On December 30 th, Ms. Qi s second period came without any low back pain or abdominal pain. A third formula was prescribed after her period stopped: Formula: Dang Gui 10g, Bai Shao 10g, Chuan Xiong 10g, Shu Di 15g, Tu Si Zi 30g, Fu Pen Zi 15g, Bu Gu Zhi 10g, Lu Jiao Shuang 15g, Zi Shi Ying 30g, Rou Cong Rong 15g, Sang Ji Sheng 30g, She Chuang Zi 15g. This formula was taken for one month. Ms. Qi s period did not come the next month so herbs were discontinued and she was observed until one week past the date of her next scheduled period. At that time a urine test was administered and it was determined that she was pregnant. In 1997 Ms. Qi delivered a healthy baby boy with a normal labor. Discussion: symptom analysis shows that Ms. Qi had Kidney Yang deficiency causing low back ache and aversion to cold along with Qi stagnation, Chong-Ren disharmony, uterine Meridian blockage and Blood stasis in the uterine collateral causing Blood not to circulate normally resulting in heavy periods. In other words, Blood stasis caused heavy periods with bright red Blood, Blood clots, low abdomen pain and low back pain. The root cause of the infertility was disharmony between Chong and Ren with the Kidney deficiency. In the initial formula, the herbs Ba Ji Tian and Rou Cong Rong were used to tonify Kidney Yang and replenish Kidney Yin and essence, and Zi Shi Ying was used to tonify and warm the Lower Jiao. Since the patient had painful periods Dan Shen and Chi Shao were added to activate Blood circulation and remove Blood stasis. Ji Xue Teng nourishes blood and regulates Chong. Gui Zhi, Wu Yao and Gan Jiang were used to warm and open the meridians, while Fu Ling was used to astringe the Spleen and tonify the Kidney. Ru Xiang and Mo Yao were added to relieve pain and regulate the Chong and Ren, and Ju He to open the collaterals and dispel stagnation. After her period the pain was reduced and since she was close to ovulating, Chai Hu and Lu Lu Tong were used to regulate Qi and stimulate ovulation in the second formula. Dang Gui, Chuang Xiong and Ji Xue Teng were used to nourish blood and regulate the Chong Meridian; Dan Shen was used to active Blood circulation and remove Blood stasis; Ba Ji Tian and Bu Gu Zhi were used to tonify the Kidney and replenish Essence; Zi Shi Ying was used to warm and tonify the Lower Jiao and regulate the Chong Meridian; Ju He and Niu Xi activate Blood circulation to open the collaterals; Gan Cao harmonizes all of the herbs. After her period, Ms. Qi was given Si Wu Tang to nourish Blood and regulate the Chong Meridian. Tu Si Zi and Fu Pen Zi were added to nourish Kidney Yin, warm Kidney Yang and replenish Kidney Essence. These herbs together make the Kidney Qi flourish, fill the Kidney Essence and harmonize the Chong, Ren, Blood and Qi. Case Study 2 Ms. Wu, female, 32 years old, first visited on March 13 th, She has been unable to conceive for five years along with spontaneous lactation for the past year. Her period history shows onset of menarche at 16 years old and a 5/15-20 day cycle with scanty menses. Ms. Wu had amenorrhea for seven months in 1990 at which time she had a progesterone injection and her menses resumed, through her flow is scanty and accompanied by distending abdominal pain and galactorrhea. Her last period was on February 25 th. Her tongue was normal in colour with a thin white coating and she had a wiry pulse. Ultrasound showed a small and bicornuate uterus. Fallopian tests showed blockage in the isthmus; basal body temperature was monophasic; and prolactin levels were 135ng/ml. Her husband s semen levels were normal. Diagnosis: infertility, amenorrhea Treatment Principle: tonify Kidney, regulate Chong, remove Blood stasis, open the collaterals