In vitro fertilization/embryo transfer (IVF/ET) is a technique of reproductive medicine. Following controlled ovarian stimulation (COS), eggs are retrieved from the ovaries. After these eggs are cultivated and fertilized and have developed into embryos of a certain size, they are transferred to the uterus for implantation and growth.

Children “created” by means of IVF/ET treatment are referred to in China as “test-tube babies.” Since the first test-tube baby was born in Great Britain in 1978, IVF/ET procedures have experienced rapid growth and development, for example with the following techniques:

• intracytoplasmic sperm injection (ICSI)
  
• cryoconservation and transfer
  
• co-cultivation
  
• assisted hatching
  
• blastocyst transfer
  
• in vitro maturation (IVM)
  
• pre-implantation diagnosis (PID)

These techniques are common all over the world. With their assistance, reproductive medicine has been able to help many infertile couples so far.

The IVF/ET procedure is a milestone in the treatment of infertility. But even with this method there are difficulties, such as the low success rate (live birth rate 8–30%), low responders (9–20%), high drop-out rate (15–24%), long treatment duration, and high costs, to name just the most important ones.

For these reasons, more and more couples are turning to TCM for support. Apart from this fact, many open-minded IVF/ET specialists have begun referring their difficult patients to TCM practitioners whom they trust, to receive further assistance

TCM has a history of treating infertility that goes back more than a thousand years. It has therefore gathered a wealth of experience with resulting opinions and scientific foundations. Already in the 11th century BCE, the famous physician Zhou Yi stated: “Infertility refers to the state when women are not pregnant after 3 years.” This is the first mention of this disorder with reference to a time frame.

The chapter on “childlessness” (wu zi) in the classic Zhu Bing Yuan Hou Lun (On the Origins and Symptoms of the Various Diseases), which was composed in the Sui period (581–618 CE), elaborates: “Disharmony in the chong mai and ren mai is the main cause of women’s diseases.”

Since then, TCM has developed a complete scientific system for the physiology, pathology, and treatment of infertility, with excellent results. Like Western reproductive medicine, TCM has also grown step by step in this area and continues to achieve better and better results.

From October 2000 to February 2006, I have supported IVF/ET treatments with TCM in China and abroad (Israel and Swizerland) and gathered detailed data on 86 cases. The average age of the patients was 34.4 ± 3.6 years (the range was 27–44 years). The mean duration of infertility was 7.3 ± 3.2 years (the range was 2–20 years). There were 51 cases of primary infertility (59.3%) and 35 cases of secondary infertility (40.7%).

Among these patients, the following causes of infertility were found:

In spite of the fact that the question might seem superfluous and that we could argue that IVF/ET treatments are appropriate for all types of infertility, opinions differ on this topic.

Complications that can arise in the course of IVF/ ET or ICSI/ET procedures include for example:

• The miscarriage rate (18.4–30%) is higher than in natural pregnancies (10–18%).
  
• Abdominal pregnancies occur more frequently (3.8–5%) than in natural conception (2%).
  
• The number of multiple pregnancies is high (30%).
  
• The rate of ovarian hyperstimulation syndrome (OHSS), a critical iatrogenic complication, lies around 23.3%.
  
• Micromanipulation of gametes has raised the question of the safety of ICSI; we must consider the fact that a slight rise in chromosomal deviations in 1082 caryotypes has been noticed in ICSI children, without defects.

In addition, the low success rate, high costs, and other factors that we have already mentioned at the beginning of this chapter discourage many couples from deciding on these methods.

We have a few suggestions on this topic:

Treatment with TCM should be initiated in accordance with the principle of pattern identification as the basis for determining treatment (bian zheng lun zhi). At the same time, we should look for the cause of the infertility. TCM offers a rich treasure trove of experience. If no serious circumstances are found, the couple will get pregnant after a short time. We can achieve even better results by combining Chinese pattern identification with biomedical pathology. For example, a female patient whose infertility is accompanied by problems such as endometriosis, PCO syndrome, luteal phase defect (LPD), or dysfunctional uterine bleeding can become pregnant when treated with TCM.

According to my experience, some patients who had previously received various IVF/ET or ICSI/ET treatments with no success were able to have children after treatment only with Chinese medicinals.

If no pregnancy has occurred after 3–6 months of TCM therapy, it should be combined with biomedicine. A patient with PCOS, for example, can supplement TCM treatment with Clomifen/hCG or Metformin, to profit from the advantages of both methods.

If endometriosis patients are still not pregnant after several months of TCM treatment, a laparoscopy is advised. Afterwards, we should continue treatment with TCM because the pregnancy rate 6 months after laparoscopy is high. This results either from the stimulation of ovulation or from the additional softening of adhesions and tissue growths, as a result of which the function of the ovaries and fallopian tubes is supported.

In infertility due to occluded fallopian tubes, it has proven effective to treat patients internally and externally for 2 months with TCM and then to repeat a patency test with fluid instillation (introduction). If at this point we find signs of an opening such as reduced pressure or less fluid backflow, treatment should be continued. In the author’s opinion, an opening of the fallopian tubes occurs within 2–6 months in nearly half of the patients receiving this combined therapy.

Good results can also be achieved with TCM in the treatment of male infertility patients in whom sperm density is less than 20 million/mL and sperm activity is reduced.

Most problems can be solved with TCM or in combination with biomedicine without requiring IVF treatment. In these cases, we spare patients the massive side-effects of medications that are otherwise given in high dosages, such as hot flashes, localized reactions at the puncture sites, mood swings, headache, or menstrual problems. Most importantly, TCM does not carry any risks comparable to those of IVF/ET or ICSI/ET treatment. In addition, the costs are much lower.

In the following cases, it is advisable for patients to immediately undergo IVF/ET or ICSI/ET treatment, for the sake of saving time:

• For women in whom both fallopian tubes are occluded, especially when the obstruction is found in the proximal part of the tubes, or for women whose fallopian tubes were removed in a fallopian tube removal; for women who have a prehistory of pelvic tuberculosis because this disorder increases the likelihood of an abdominal pregnancy since the TB has destroyed the inside of the ovaries. Even if treatment with TCM would result in patency, it would still be difficult to restore peristalsis and the walls of the tubes. Regardless of this fact, women above the age of 38 should directly undergo IVF/ET treatment in view of the quality and number of their eggs.
  
• For women whose partner suffers from severe oligo-astheno-teratozoospermia syndrome (OATS), because here it is impossible to produce a child naturally or via intrauterine insemination (IUI).

Depending on the case, there are different protocols for controlled ovarian stimulation and fertilization methods. Nevertheless, the principle of IVF/ET treatment is always the same: in general, we find the stages of down-regulation, retrieval of the ovum, and embryo transfer. The treatment principle of TCM changes in accordance with the different steps. In our experience, there are six stages that we can accompany with TCM:

1. Preparatory
   
2. Down-regulation
   
3. Menstrual
   
4. Oocyte maturation
   
5. Follicle punction
   
6. Embryo transfer

In order to successfully carry out an IVF/ET or ICSI/ET treatment, it is important to balance the patient’s yin and yang, qi and blood, the viscera and bowels (zang and fu) for 2–3 months by means of TCM.

Common patterns during the preparatory and regulatory phases are:

• kidney vacuity with liver qi stagnation
  
• liver fire due to liver qi stagnation
  
• vacuity heat due to liver and kidney yin vacuity
  
• yang vacuity in the kidney and spleen, in combination with dampness and phlegm
  
• damp-heat accumulation in the lower burner

The treatment principle for prescribing medicinals and/or selecting acupuncture points depends on a differential diagnosis.

The ideal condition for an IVF/ET treatment includes:

These deviations from the ideal state provide the explanation for a continued lack of pregnancy in spite of the fact that the biomedical preconditions, for example, an endometrial thickness of 10 mm, good embryo morphology, and an optimal hormonal state, are fulfilled. TCM always treats the whole person. A healthy appetite and sleep, balanced emotional state, and regular digestion are good and important signs for the patient.

In this phase, the patient receives high doses of GnRH-a (gonadotropin-releasing hormone agonist), often for a “long protocol” of COS, to inhibit the activity of the reproductive axis and the body’s own hormones. This is called down-regulation and often begins in the luteal phase of the previous cycle. Patients with endometriosis and adenomyosis are treated for 2–3 months to control the endometriosis lesions. Patients with an irregular cycle or FSH (follicle-stimulating hormone) levels of more than 15 U/L are often given the “pill,” for example Marvelon, for 1–3 months prior to the start of IVF/ET treatment.

Replenish and supplement blood and essence to regulate and strengthen the chong mai and ren mai.

Rx. Yang Xue Tian Jing Fang (, Bloodnourishing Essence-replenishing Formula) with modifications:

• dang gui (Angelicae sinensis radix)
  
• chuan xiong (Chuanxiong rhizoma)
  
• bai shao yao (Paeoniae radix alba)
  
• e jiao zhu (Asini corii gelatini pilula)
  
• shu di huang (Rehmanniae radix praeparata)
  
• he shou wu (Polygoni multiflori radix)
  
• gou qi zi (Lycii fructus)
  
• tu si zi (Cuscutae semen)
  
• chai hu (Bupleuri radix)
  
• shan zhu yu (Corni fructus)
  
• fu ling (Poria)

Note: It is necessary to select one of these groups for the main formula.

Necessary Additions:

• For kidney yang vacuity, add rou cong rong (Cistanches herba) and fu pen zi (Rubi fructus).
  
• For kidney yin vacuity, add nü zhen zi (Ligustri lucidi fructus) and han lian cao (Ecliptae herba).
  
• For excessive heat, replace chuan xiong with dan shen (Salviae miltiorrhizae radix) or chi shao (Paeoniae radix rubra).

Modifications:

• liver qi stagnation: add yu jin (Curcumae radix) and xiang fu (Cyperi rhizoma)
  
• insufficiency of qi: add dang shen (Codonopsis radix) or tai zi shen (Pseudostellariae radix)
  
• yin vacuity: add sha shen (Adenophorae seu glehniae radix), yu zhu (Polygonati odorati rhizoma), or huang jing (Polygonati rhizoma)
  
• insomnia: add suan zao ren (Ziziphi spinosi semen), bai zi ren (Platycladi semen), zhen zhu mu (Concha margaritifera), or yuan zhi (Polygalae radix)

The “down-regulation phase” or “supplementing phase” serves to replenish and supplement blood and essence without stimulating the reproductive function, which would run counter to the downregulation by GnRH-a.

• CV-12, CV-6, CV-4, ST-36, SP-6, KI-3, GV-20, HT-7, LR-3

During this phase, the menstrual blood is flowing. Menstruation is the beginning of a new cycle. During this time, it is important to “drain instead of storing” (xie er bu cang ) and to “create a smooth passage by freeing the flow” (yi tong wei shun ). The blood should be freed and purged gently to cause the old endometrium to be eliminated completely and thereby ensure that the new endometrium can grow in a renewed environment. Treatment begins 2–3 days before the onset of menstruation and continues for another 3–4 days afterwards.

Nourish blood and support the flow of blood to regulate menstruation.

Rx. Tiao Jing Fang (, Menses-regulating Formula), with modifications:

• dang gui
  
• chuan xiong
  
• shu di huang
  
• bai shao yao
  
• pu huang (Typhae pollen)
  
• xiang fu
  
• yi mu cao (Leonuri herba)
  
• he shou wu
  
• gan cao (Glycyrrhizae radix)

Modifications:

• heavy menstrual periods or periods with clots: add chai hu, qian cao (Rubiae radix), powdered san qi (Notoginseng radix), or pu huang tan (Typhae pollen carbonisatum)
  
• scant and dark periods: add ze lan (Lycopi herba), dan shen, hong hua (Carthami flos), or tao ren (Persicae semen)
  
• dysmenorrhea: add yan hu suo (Corydalis rhizoma), chuan lian zi (Toosendan fructus), wu yao (Linderae radix), or li zhi he (Litchi semen); for cold pain, add wu zhu yu (Evodiae fructus) and gao liang jiang (Alpiniae officinarum rhizoma)

• CV-6, CV-3 SP-6, SP-10, SP-8, LR-3

It is possible that the menstrual period will fail to arrive after 2–3 months of taking GnRH-a. Be this as it may, as soon as stimulation of the oocyte development is initiated in the course of the IVF treatment, continue with phase 4 (oocyte maturation phase), under certain circumstances also bypassing the menstruation phase.

This phase corresponds to the length of time that the patient is taking gonadotropin-FSH or hMG (human menopausal gonadotropin) to stimulate the maturation of the oocyte.

Warm and supplement the kidneys, quicken the blood, and regulate the chong mai and ren mai, to promote oocyte maturation.

Rx. Zi Shen Tiao Chong Fang (, Kidneyenriching Thoroughfare-regulating Formula), with modifications:

• dang gui
  
• chuan xiong
  
• dan shen
  
• tu si zi
  
• qou qi zi
  
• ba ji tian (Morindae officinalis radix)
  
• xu duan (Dipsaci radix)
  
• zi he che (Hominis placenta)
  
• su mu

Note: It is necessary to select one of these groups for the main formula.

Necessary Additions:

• kidney yang vacuity: add lu rong, yin yang huo, ji xue teng (Spatholobi caulis), and rou gui
  
• kidney yin vacuity: add gui ban (Testudinis plastrum), nü zhen zi, han lian cao, chi shao, or mu dan pi (Moutan cortex)

Modifications:

For vacuity of qi and yin and insomnia, add the same medicinals as in the down-regulation phase.