3 Fertility Treatment and Pregnancy—Foundations of TCM Prerequisites for the creation of new life include, on the one hand, “external” conditions like harmony and love in the relationship. On the other hand, everything must also be ready “internally” so that the fertile sperm finds a mature egg ready for implantation and a good environment—that is, a receptive uterus. From the perspective of TCM, all viscera, bowels, and channels participate in this process. Only their harmonious cooperation ensures that fertility disorders are prevented: According to the biomedical definition, a woman is regarded as infertile if she fails to become pregnant within 2 years in spite of a normal sex life and healthy sperm from the man.5 The search for causes should therefore initially turn to some general considerations. This includes a general constitutional weakness of kidney essence in the woman, that is, on the one hand a lack of prenatal essence because her own parents were already quite old or in bad health during conception, and on the other, a lack of postnatal essence due to overwork but also to excessive or too early sexual activity. Physical exhaustion from hard labor but also from excessive sports causes not only kidney yin but also spleen and kidney yang to fade. Too much sex, especially in one’s younger years or during puberty, can have a negative effect on the kidney, ren mai, and chong mai. Exposure to cold and moisture, but also insufficient clothing—for example, due the fashion of exposing the belly—can displace the uterus, ren mai, chong mai, as well as the channels, as a result of which fertilization becomes more difficult. Especially during menstruation, women should avoid cold and wetness and should not play sports excessively. Likewise, an excessive consumption of cold, fatty, and phlegm-forming foods or drinks can cause the fallopian tubes to shift because of the moisture that is formed in the lower burner. The primary differentiation in the treatment of infertility lies in the distinction between patterns of vacuity and repletion. Do we have to supplement or do we have to eliminate pathogenic factors? In this context, let us first clarify some important terms. Jing, qi, and xue are vital substances that are essential for reproduction. Their unimpeded circulation guarantees the harmonious progression of all body functions. The vital essence jing consists of two components: first, the congenital prenatal potential, the constitution so to speak, that was inherited from the parents. Second, it consists of the acquired jing, which a person can increase or at least maintain throughout the course of his or her life. In accordance with the laws of nature, jing runs out towards the end of life. The amount of prenatal jing that a person is born with is predestined by fate. We can try to use it sparingly and continuously replenish the store in the kidney with acquired jing by a correct lifestyle (yang sheng, “nurturing/cultivating life”). In addition to proper diet, lifestyle, and breathing and movement exercises, the preservation of jing also includes advice on sexuality. Jing is stored in the kidney. When it is strong, it enables women to still bear children after their 40th birthday. In addition, strong jing is the foundation for a healthy shen. Shen, the spirit, the love of life, our social competence, our talents and skills, all of these can only develop if a good and sufficient supply of jing exists. Couples seeking a child should not disregard their own age completely since the parents’ advanced age and weakening health is one cause for a lack of prenatal jing in the child: “The Yellow Emperor replied: ‘But there were people who in spite of being old in years were able to engender descendants. How is this possible?’ Qi Bo replied: ‘These are people whose natural end of life should be set higher. The beat of their pulse remains active, and an excess of semen remains in their testicles. Even though they beget children, their sons will not survive past the age of 46 and their daughters will not grow older than 49, because at this time the strength of heaven and earth will be exhausted.’”8 Weak jing leads to weak, sickly children, delayed puberty, and partly to underdeveloped primary and secondary sexual characteristics. In women, we often find not only menstrual irregularities, but also eggs of lower quality, which can then be fertilized only with difficulty and often produce weak embryos. In the man, a lack of jing causes low-quality sperm or a reduced sperm count. Generally speaking, a lack of kidney jing has a complicating effect on reproduction. Qi has many diverse functions; without its moving attributes, for example, ovulation would not take place, the egg would not migrate, and the sperm would not move either. The functions of qi are: Any state of qi vacuity is usually rooted in the spleen or lung, since the lung directs the qi and the spleen, by its moving and transforming activity, is the source of qi. Lack of qi manifests in shortness of breath, fatigue, a weak voice, lack of appetite and strength, and sometimes diarrhea and spontaneous sweating. The pulse is weak and vacuous, the tongue pale with a whitish fur. Qi can wane in its movement and cause stagnations. Frequently, the decisive is an insufficient regulatory function in the liver. These stagnations can be felt as palpable abdominal “knots” that change their location and can even disappear altogether. They are accompanied by painful, pulling feelings of tension and pressure in the entire abdominal region, with irritability, emotional instability, and periods of mental depression. In men with sterility, we often find enduring qi stagnation, commonly accompanied by a lack of jing. The pulse is stringlike or tight, the tongue mildly purple-colored. A direct translation of xue as “blood” does not do justice to the Chinese understanding of the function and attributes of blood. Rather, blood is the material form of qi, it constitutes the substantial foundation of the shen, and it nourishes and moistens the body. With the help of the spleen, the blood of the body xue shui (blood-water) is formed from ying qi (constructive qi) and bodily fluids; spleen qi also contains it in the blood vessels. The blood is stored in the liver, especially in the muscles (uterus!). The liver thereby also regulates the volume of blood. Ultimately, though, heart qi dominates the blood, while the lung is also involved as the source of qi. The menstrual blood, on the other hand, the jing shui (menstrual water), is produced from kidney water and is transformed with the help of the heart, liver, and spleen. Kidney water or kidney yin is hence the foundation for the formation of menstrual blood. The kidney is the storehouse of prenatal jing and yuan qi (original qi). It is also the source of menstrual blood and of sexual maturity, the so-called tian gui. Tian means heaven, and gui is the 10th heavenly stem from the old Chinese calendrical system that ordered the macrocosm. It is associated with the element water. This “heavenly water” is present in the human body from birth on, but only manifests with sexual maturity. In the man, the tian gui regulates the transformation of blood into semen; in the woman, it starts the menstrual period and provides for the moistening of the vagina. Thus, girls begin menstruating at the age of 14 because this is when the heavenly water has arrived. The ren mai opens and fills with qi, the chong mai fills with blood, and the girl is ready to conceive. In the man, the tian gui manifests in the form of sperm at age 16—as is described in the Huang Di Nei Jing (The Yellow Emperor’s Inner Classic) (see below). The material foundation of the menstrual blood is thus the heavenly gui, manifesting as menstrual fluid. This is therefore not formed from regular blood, but from prenatal essence that is stored in the kidney and materialized with the assistance of the heart. Kidney essence thereby has a profound influence on female physiology (and, of course, equally on male physiology), from puberty through pregnancy up to menopause. Functions of the heavenly water tian gui are: General lack of blood causes insufficient nourishment of the mucous membranes of the uterus and ultimately also of the embryo. Nidation of the fertilized egg is impeded because the endometrium is insufficiently formed. A lack of liver blood in particular supplies the uterus with an insufficient amount of blood, the menstrual period is scant, and the cycle can become irregular or even cease altogether. A weak menstrual period with rather pale blood and in general a longer cycle are typical of this pattern. Such women are pale, they feel tired, without energy, often dizzy, and generally rather depressed. Often, the vision is also impaired, the skin is dry, and we find constipation. The tongue is pale and thin, the pulse rough or else fine. Lack of blood on its own is more common in women; in men, we are more likely to find qi disorders with stagnation of qi, blood, or fluids instead. This combination manifests in a general state of exhaustion, palpitations, paleness, shortness of breath, dizziness, and tinnitus. Erections are weak, and the more exhausted and overburdened the patient feels the more problematic they become. The pale tongue shows a thin whitish fur, the pulse is weak and vacuous. Typical of Blood heat are such symptoms as a short cycle, sometimes up to twice in 1 month, accompanied by a feeling of heat, thirst, and unrest. The tongue is red, the pulse is rapid and surging. In patients with Blood stasis, the menstrual period is irregular and painful with dark and often clotted blood because the chong mai is unable to drain completely. Such patients feel irritated, nervous, and restless. The tongue is purple, possibly with macules and blocked sublingual veins, the pulse is stringlike or rough. Women’s physiology is determined by blood; it is the source of fertility, conception, and pregnancy. In contrast to men, whose orgasms depend primarily on qi, women’s bodily functions are controlled by blood, clearly visible in the blood of menstruation, which prepares their body every month. TCM refers to that part of the female sexual organs that is encircled by the liver channel as the actual sexual organs yin qi. The uterus—which also includes the fallopian tubes and ovaries—is the key reproductive organ in women and the point from which menstruation originates. In the Huang Di Nei Jing Su Wen, the uterus is referred to as “woman’s protective cover,” nu zi bao, and is included among the six “extraordinary organs” because it fulfills both the function of a yang organ (menstruation and childbirth as elimination) and of a yin organ (blood storage and nourishing the embryo). It “transforms” the fetus from the man’s essence (his sperm) and the mother’s blood, and protects and nourishes it until childbirth: Anatomically speaking, the uterus, which corresponds to the dan tian, lies in the lower burner between the bladder and rectum. It is a structure of circuits that is linked to the abdomen through the points CV-3, CV-4, and CV-6 and to the kidney channel through an internal branch. Via the uterine network vessel bao luo, the uterus is linked to the kidney below; above, it connects to the heart via the uterine vessel bao mai (Figs. 7.1). Kidney jing and heart blood are therefore also responsible for a normal menstruation and for fertility. If heart blood is lacking, heart qi fails to descend into the abdomen; if kidney jing is lacking, the menses fail to arrive. Fig. 7.1 The connection of the uterus to the heart and kidney. The bao mai and bao luo connect the heart and kidney to the uterus and transport jing and menstrual blood from the kidneys as well as blood from the heart to the uterus. In addition, heart and kidney qi direct the opening and closing of the uterus: The opening of the uterus is initiated by the heart. The uterus opens during ovulation to let the egg in, during sexual intercourse for the sperm, and also during menstruation to allow the blood to drain out. A stagnation or blockage in this area—for which emotional and mental factors play an important role—prevent the egg or sperm from entering the uterus. Likewise, the menstrual blood can no longer drain out freely. The kidneys regulate the closing of the uterus after menstruation and after ovulation, when the egg has arrived in the uterus, and, of course, also after fertilization, to keep the embryo safe. A weak kidney qi would hence contribute to a miscarriage because of a failure to close the uterus. Similarly, intermenstrual bleeding and dribbling of blood after the end of the actual menstrual period can be attributed to a weakness of the kidney in this area. After experiencing shock or great stress, the heart and kidney can be practically traumatized. This often leads to heart heat, which causes heart qi to stagnate and, if the uterus opens suddenly, can cause a miscarriage or intermenstrual bleeding. “When a girl turns 7, the energy of her kidneys increases, her teeth change, and her hair grows longer. When she turns 14, menstruation starts, the girl can get pregnant, and the pulses in the great thoroughfare channel* beat strongly. The girl menstruates regularly and hence can bear children. When the girl turns 21, the energy of her kidneys is normal, the last teeth have emerged, and the body is fully grown. At the age of 28, the woman’s muscles and bones are solid and strong, her hair growth has reached its full length, and her body flourishes and is fertile. At the age of 35, the pulse in the area of the sunlight** wanes, her face becomes wrinkled, and her hair begins to fall out. At the age of 42, the intensity of the pulse in the area of the three yang regions*** in the upper half of the body wanes, her whole face is covered with wrinkles, and her hair begins to turn white. At the age of 49, she can no longer become pregnant, and circulation in the large thoroughfare pulse wanes. The gates of menstruation are now closed. Her body declines, and she can no longer bear children.”8 The man’s physiology is primarily determined by qi. In the place where the uterus is located in the woman in the dan tian, we find the “sperm chamber” in the man. The testicles and the scrotum are the “palace of jing”; here, the man stores the essence jing in the form of sperm. Sperm, which is generally yin, from an energetic perspective consists of a yang part, namely the rapidly moving sperm, and a yin part, the nourishing seminal fluid. Thus, we must, for example, supplement yang or qi in cases with slow sperm cells, but supplement yin or essence in cases with low sperm quality. “When a boy turns 8, the energy of his testicles is fully developed; his hair grows longer, and his teeth change. At the age of 16, the energy of his testicles increases, and he thus begins to discharge semen. He has a surplus of semen, which he strives to get rid of, and if the male and female element unite in harmony at this point, a child can be conceived. At the age of 24, the energy of the testicles is normal in the man; his muscle [sic!] and bones are solid and strong, the last teeth have emerged, and the body has reached its full size. At the age of 32, the muscles and bones develop their full splendor, the man’s flesh is healthy, he can withstand physical strain, and he is fertile. At the age of 40, the man’s testicles become smaller and his hair and teeth begin to fall out. When the man turns 48, his male strength is exhausted or decreases, wrinkles mark his face, and his hair turns white at the temples. At the age of 56, the energy of the liver wanes, his muscles no longer move faultlessly, his eliminations of sperm are exhausted, his vital strength decreases, his kidneys decline, and the physical strength comes to an end. At the age of 64, he loses his teeth and hair. The kidneys regulate the water flow and store energy that is supplied by the five viscera and six bowels. Semen can only be discharged if the five viscera are filled with energy. But if they are dry and empty at this time, the muscles and bones degenerate, the sperm for conception is exhausted, and the hair at the temples therefore turns white, his body fills up and becomes heavy, his gait is no longer straight, and he is no longer able to produce offspring.”8 ___________ *An old collective name for the pulses of the ren mai and chong mai. The eight extraordinary vessels, also called “miracle channels,” are reservoirs of energy, with a special significance for embryonic development and reproduction. They distribute yin, yang, qi, and blood outside of the system of the main channels and viscera and bowels. For conception and pregnancy, the chong mai—the thoroughfare vessel—and the ren mai—the conception vessel—are the most important channels. For the time after ovulation and for menstruation, the chong mai as the “sea of blood” is the most important extraordinary vessel. It regulates the blood supply and the movement of blood in the uterus. The ren mai is highly significant for a woman’s ability to conceive and for supplying the internal and external genitals. Disorders in the cervix, vagina, and vulva can be influenced through the ren mai. Nan Jing 66: “The ‘moving qi between the kidneys is what creates human life, and the root of the 12 channels. Therefore [this location] is called ‘source’ yuan.”2 The ren mai and chong mai originate in the area of the “moving qi” (dong qi) between the kidneys and from there run downwards through the uterus to CV-1. Here, the ren mai emerges to the surface and runs upward to CV-24, encircles the mouth, and enters the eyes at ST-1. The chong mai emerges to the surface at ST-30 and runs along the kidney channel up to KI-21 or KI-27, then crosses the throat, encircles the mouth, and seeps “into yang and moistens yin” at the forehead. Other branches of the chong mai run through the legs and back. The ren mai is also called the “sea of the yin channels” because it provides all yin substances (blood, essence, fluids) that are involved in the hormonal changes in a woman’s life: puberty, conception, pregnancy, and menopause. After menopause in particular, we can nourish yin through the ren mai to alleviate the symptoms of vacuity heat. The chong mai as the “sea of blood” provides the blood for menstruation, moves it, and moistens the essence. Vacuity in the chong mai causes amenorrhea or prolonged cycles; qi stagnation or blood stasis cause premenstrual syndrome (PMS) and dysmenorrhea. The du mai—the governing vessel—also originates in the space between the kidneys, runs downward through the uterus, and emerges to the body’s surface at CV-1. Its main branch runs through the spinal column to the head, enters the brain, and ends on the upper lip at GV-28. Several classical sources define the du mai as a branch of the liver channel; others see the du mai and ren mai as two branches of one channel: du mai with yang characteristics, ren mai with yin characteristics. Of clinical relevance, though, is primarily the fact that one of the side branches of the du mai encircles the vagina. Hence, we treat not only the ren mai in vaginal problems but also the du mai, especially in cases with pronounced kidney yang vacuity. The reason for this is that the du mai represents the influence of the ming men (see also p. 87) and ministerial fire. Su Wen, Chapter 60, explicitly defines the cause of infertility in women as a du mai disorder: “Du mai disorders can cause stiffness of the spinal column and pulling pain in the back. The du mai originates in the center of the bones below the lower abdomen*; in women, it penetrates to the inside and connects with the ting kong (obscure term associated with the external opening of the urethra), kong being the external opening of the urethra. A network vessel circumvents the genitals and connects to the area between the front and back of the pubic region, another branch circumvents the buttocks… The branch that runs upwards in a straight line from the lower abdomen crosses the center of the navel, ascends, crosses the heart, enters the throat, runs upward to the cheek, circumvents the lips, and connects with the center below the eyes. When disorders originate here, the qi surges upward from the lower abdomen straight against the heart and causes pain, and the patient is unable to urinate or defecate. This is chong shan, pain from surging [qi]. In women, [we see] infertility, inhibited urination, hemorrhoids, incontinence and dry throat. When the du mai is diseased and you want to treat the du mai, treatment is applied above the pubic bone, in serious cases at qi xia ying**.”7 The dai mai, the girdling vessel, which—as the name implies—encircles the body like a girdle at the level of the waistline, plays a harmonizing role, due to its connections to the leg channels. Through LR-13, it affects the smooth flow of liver qi, a good starting point in liver qi stagnation. At the same time, LR-13 is also the mu point (alarm point) of the spleen; hence, you could, for example, also treat vaginal discharge, that is due to damp-heat in chronic spleen vacuity, via the dai mai. The dai mai influences the rise and fall of the energies of the spleen, liver, and kidney. It must be relaxed and stretched, so that the qi of the uterus and the essence can flow but at the same time are also supported. If the dai mai is too slack, this can lead to liver, spleen, and kidney vacuity. Qi is unable to rise, the organs become feeble (prolapse), and the fetus does not receive the necessary stability either, which can result in miscarriage. Starting at KI-6, the yin qiao mai—the springing vessel—runs along the inside of the legs through the external genitals and the thorax up to the inner corner of the eyes. It influences the organs of the pelvis and is used in states of repletion in the lower burner (feeling of pressure in the abdomen, myomas, retained placenta). Repletion patterns of the external genitals can also be treated through the yin qiao mai.
7 Physiology and Pathology of Fertility and Reproduction from the TCM Perspective
Dagmar Hemm
The Energies Jing, Qi, and Xue
The Essence Jing
Lack of Jing
The Moving Force Qi
Lack of Qi
Qi Stagnation
The Blood Xue and the Special Characteristics of the Menstrual Blood Jing Shui
Lack of Blood
Lack of Xue (Blood) and Qi
Blood Heat
Blood Stasis
Blood and Qi in Men and Women
Female Physiology
Male Physiology
**These are the pulses of the stomach, large intestine, and small intestine.
***That is, the tai yang, yang ming, and shao yang channels.
The Extraordinary Vessels
Chong Mai (Thoroughfare Vessel) and Ren Mai (Conception Vessel)
Du Mai (Governing Vessel)
Dai Mai (Girdling Vessel)
Yin Qiao Mai (Yin Springing Vessel)
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