25 Supporting the Couple in Successful and Failed Fertility Treatment
Andreas A. Noll, Gudrun Kotte, and Sabine Wilms^*

The success of fertility treatment depends on a large number of factors. In addition to physiological and pathological obstacles, which are found in the physical functions of the man and the woman, we must not ignore psychological and sociocultural aspects either. The latter concern the valuation of children and of pregnancy in our society as well as norms determined by reproductive medicine. In addition, individual life and work situations, cooperation with the practitioner, and the experiences gained in the course of fertility treatment all play significant roles as well.

Ultimately, one factor that is not predictable always remains: “coincidence,” “divine providence,” dao, shen, or “fate.” Neither reproductive medicine nor TCM can provide a guarantee for successful conception and pregnancy—both methods can, however, assist in creating the most “fertile soil” possible for a new life.

While reproductive medicine concentrates primarily on the removal of physiological obstacles, TCM pays additional attention to the equilibrium of all immaterial processes in their organic interplay—and thereby also to patients’ psychological-emotional balance. A conversation about the potential effects of any intensive treatment with reproductive medicine on this balance is therefore one aspect of patient support that TCM can provide. At the end of any fertility treatment, we should always face healthy patients—whether there will be three, two, or even just one.

In light of the detailed contributions on supporting fertilization and conception in this book (see Chapters 19, 22, and 23), the following chapter concentrates on two aspects in the support of couples in fertility treatment:

• on supporting a pregnancy after successful conception and
  
• on options for additional support if the wish for a child cannot be realized

Supporting Pregnancy

Promoting the health of pregnant women and avoiding possible harm to mother and child has been a central issue in TCM for many centuries. The Chinese scholar-physician Sun Simiao (581–682 CE) was not the first, but perhaps the most famous “King of Medicine” (yao wang), who concerned himself with promoting the development of the fetus in the mother’s womb. His book, Bei Ji Qian Jin Yao Fang (Essential 1000-Gold Formulary for Emergencies), became the standard classic until the 19th century and still serves as the most im- portant reference text for this chapter (see also Chapter 8).

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* Please see Bei Ji Qian Jin Yao Fang—Essential Prescriptions worth a Thousand in Gold for Every Emergency (The Chinese Medicine Database, 2008) and The Transmission of Medical Knowledge on ‘Nurturing the Fetus’ in Early China (Asian Medicine: Tradition and Modernity, 2005), which were used as a source for this chapter.

In the Chinese classics, pregnancy is commonly divided into 10 months, counted in accordance with the lunar calendar. In each month, a different channel nourishes the child. Two months each and their respective channels are associated with one phase:

An example: a woman with a clear weakness of the center will probably develop symptoms during the time associated with the earth phase, that is, in the fifth and sixth month. At the same time, she will respond particularly well to strengthening the center during this phase. Tuning in to the internal processes anew each month, as this theory encourages us to do, presents a valuable opportunity for both the practitioner and the pregnant woman to consciously perceive and thereby stabilize the processes inside her. While the recommendations appear to be directed strictly at the woman, the father of the developing child is invited implicitly to look inside himself as well because he also experiences all the phases of the pregnancy. In this context, a European study of the effects of paternity on men’s psyche and health is interesting.5

Note. The quotations and the historical core of the information presented in the following sections on prenatal care in each month of pregnancy are derived from the second volume of the Bei Ji Qian Jin Yao Fang, composed by Sun Simiao in 652 CE and translated by Sabine Wilms⁶ (see als Chapter 8). Where suitable, we have modified the information from early medieval China to incorporate our modern clinical experiences. Most notably, Sun Simiao specifically warns against the application of any acupuncture or moxibustion to the channel that is associated with nurturing the fetus in each month. These prohibitions must be seen in the context of his times, when it was quite common for medical literature to contain warnings against the reckless use of acupuncture and moxibustion. Such factors as the modern clinical reality in which acupuncture and moxibustion are practiced in Western countries, the technological advances in the manufacture of much more sophisticated, safer, and less invasive needling and moxibustion equipment, as well as the special considerations in the context of fertility treatment have led us to deviate from Sun Simiao’s advice in this point. Especially in the context of artificially induced pregnancies, we are frequently dealing with highly unstable processes that can respond well to supplementing treatment of the channel responsible for nurturing the fetus in each month. The strengthening effects of this strategy on the mother, which in turn then stabilizes the fetus and therefore the pregnancy, have been observed for several decades in the authors’ personal practice. Unfortunately, it is, after all, relatively rare for TCM practitioners to be consulted by healthy couples turning to TCM to prepare for an ideal pregnancy. Most of our pregnant clients come with serious imbalances and symptoms that have often forced them to utilize drastic biomedical interventions in order to become pregnant. In such cases, knowing and supporting the channel associated with nurturing the fetus in each month can “make or break” the success of our therapy, especially when we see a problem in a stage of the pregnancy during which one of the parents shows a constitutional weakness. For example, if the father suffers from neurodermatitis and the mother manifests symptoms in the 7th and 8th months, this could be associated with the functions of the lung and large intestine. In such a case, we can treat certain points on the supplying channel by supplementation and thereby support the channel in its function of nurturing and protecting the fetus. Again, though, it is important to emphasize here that we should limit ourselves strictly to supplementing needling.

First and Second Month—The Wood Phase

According to TCM theory, the liver channel supplies the embryo in the first month of pregnancy. This channel should only be treated by stimulation with great attention in the first month.^* The liver governs the activity of the muscles, sinews, and blood. In these first months, especially women with pre-existing stagnation of liver qi suffer from problems like mood swings, nausea, and vomiting. Tolerance to emotional strain like pressure and stress is low. It is therefore recommended that the pregnant woman not exert herself in her work. She should be able to sleep quietly and peacefully and not be afraid or worry.

Note. This and the following quotations are taken from Wilms⁶. Nevertheless, you must discuss the formulas cited here in each case with a qualified TCM practitioner in accordance with an individualized diagnosis.

“In the first month of pregnancy, yin and yang have newly combined to constitute the fetus. For cases of pain due to increased cold; sudden panic due to increased heat; lumbar pain, abdominal fullness, and tightness in the uterus from heavy lifting; and the sudden appearance of vaginal discharge, the patient should take Wu Ci Ji Tang (Black Hen Decoction) to stabilize her as a precaution.”⁶

In the second month of pregnancy, the gallbladder channel supplies the fetus. You must not needle this channel for sedation at this time, in spite of the fact that the stagnation signs that already appeared in the first month seem to suggest the need for relieving the liver and gallbladder. In light of the changeable temperature sensations in this stage of the pregnancy, the lower abdomen should be warmed gently in patients with cold sensations. In addition, Sun Simiao recommends boiled, well-tasting food with a sour flavor, barley, and chicken soup. Spicy and fishy-smelling foods should be avoided. The pregnant woman should also avoid excessively hot or cold foods in these 2 months because the embryo cannot be completed if there is too much internal heat or cold. At this time, the mother should also still guard against excitement, fright, and pressure.

“For cases of decaying [fetus] and failure to complete [the pregnancy] due to increased cold, withered [fetus] due to heat, [fetal] stirring and agitation due to being struck by wind or cold, fullness in the heart, suspension and tension below the navel, rigidity and pain in the lumbus and back, suddenly appearing vaginal discharge, and abruptly alternating [aversion to] cold and heat [effusion], Ai Ye Tang (Mugwort Decoction) is the governing prescription.”⁶

The prohibition against applying acupuncture or moxibustion on the liver channel in the first and on the gallbladder channel in the second month points to a dynamic effect that could endanger implantation and the woman’s ability to hold the fetus. In principle, this classic warns against “disturbing” the channel that is responsible for supplying the child at that time. Overall, opinions differ on beneficial or harmful acupuncture points in pregnancy and on the dangerousness of acupuncture in general. In China, the use of medicinal therapy is preferred.

Because the wood phase, like the other four phases, is associated with certain colors, taste preferences, emotions, and images in the system of correlative thinking, signs that arise at this time can serve as subtle indications that the pregnant woman finds herself in the correct season—or not. Likewise, transitions to another phase can bring to light conspicuous aspects with relevance for treatment.

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* The Qian Jin Fang prohibits the application of acupuncture and moxibustion on the specific channel.

Third and Fourth Month—The Fire Phase

In Chinese obstetrics, the notion that the mother’s inner attitude can have a formative influence on her child is found already in very early texts. Thus, the conduct of the pregnant woman in the third month was regarded as decisive for the gender of the child (see Chapter 4). This is a notion that Sun Simiao fails to elaborate on but that nevertheless plays in important role in earlier texts, such as the Tai Chan Shu (Book of the Generation of the Fetus) from the Mawangdui tombs. In China, we still find the belief that the mother’s emotional state during pregnancy has a lasting effect not only on the child’s health and intelligence, but also on the emotional state in his or her future life. Sun Simiao therefore recommends that pregnant women look at objects of great beauty and create internal clarity by meditating.

Both months are characterized by the quality of the fire phase, which corresponds to the heart, to love, joy, and a clear spirit (shen). A person’s fire is harmed either by external pathogenic factors or by emotions like fright, restlessness, or excessive excitement. Behavioral recommendations therefore aim especially at a calm, cheerful emotional state. Cultivating inner harmony and joy allows the pregnant woman, the father, and the child to develop an intimate heart-connection to each other, which has a beneficial effect on their mutual wellbeing. Especially significant in this context is cultivating the fire of the partnership, of love and sexuality, which should be nurtured particularly consciously in this time.

The pericardium channel, the channel of the “messenger of the heart,” nourishes the fetus in the third month and should therefore not be sedated. Accordingly, the pregnant woman should not be excited by grief or sorrow, nor by worries, anxiety, shock, or fright in this month; her heart and thereby her shen should remain calm and composed.

“For cases of cold conditions with blue-green feces, heat conditions with difficult urination of red or yellow urine, sudden fright and fear, anxiety and worrying, flights of temper and rage, a tendency to stumble and fall, stirring in the vessels, abnormal fullness, bitter pain around the navel or in the lumbus and back, and sudden presence of vaginal discharge, Xiong Ji Tang (Rooster Decoction) [is the governing prescription].”⁶

In the fourth month, the formation of all the child’s viscera and bowels is completed. In addition, the mother can see the changes in her body and feels the first movements of the child. Blood and qi must be strengthened more and more. As a suitable diet for this month, unpeeled and nonglutinous rice as well as soups with fish and wild goose are recommended. In the fourth month of pregnancy, the triple burner channel supplies the fetus. It is responsible for the distribution of qi both in the child and in the mother. The pregnant woman should keep her body still, harmonize her emotions and ambition, and regulate her meals. This is what is called making blood and qi thrive, as a result of which the ears and eyes are freed. Pregnancy-related vomiting here still signals a tendency to stagnation, and restlessness and fickleness are likewise symptoms of disharmony in the triple burner.

“In the fourth month of pregnancy, for seething below the heart and desire to retch, fullness in the chest and diaphragm and lack of appetite, all of which are related to the presence of cold; for urinary difficulties, urinating very frequently like a dribble, and bitter tension below the navel, which are related to the presence of heat; and for sudden wind-cold, rigidity and pain in the nape and neck, and [aversion to] cold and heat [effusion], [fetal] stirring, perhaps from fright, with intermittent and occasional pain in the lumbus, back, and abdomen, for the fetus ascending and distressing the chest, for heart vexation and inability to get rest, and for the sudden presence of vaginal discharge, take Ju Hua Tang (Chrysanthemum Decoction).”⁶

The symptoms described in this text concern different viscera and bowels, but are all caused by a weakness in the pericardium and triple burner. For the child, a disturbance in this phase means that the development of a harmonious and joyful disposition is impeded and the completion of the viscera and bowels is disturbed.

Fifth and Sixth Month—The Earth Phase

With the earth phase in the fifth and sixth month, the pregnant woman has completed the first half of her pregnancy and now experiences a stage of expansion, fortification, and stability. Women who suffered from nausea during the first few months often experience this time as pleasant and powerful. Anything that serves to support the center is recommended; in addition to a nutritious diet especially a regular daily routine without extreme strains.

“In the fifth month of pregnancy, for dizziness in the head, a deranged heart, and retching and vomiting, which are related to the presence of heat; for abdominal fullness and pain, which are related to the presence of cold; and for frequent urination, sudden fear and panic, pain in the four limbs, [aversion to] cold and heat [effusion], stirring of the fetus in unusual places, abdominal pain, oppression that suddenly puts the patient on the verge of collapse, and sudden presence of vaginal discharge, E Jiao Tang (Ass Hide Glue Decoction) is the governing prescription.”6

In the sixth month, the movements of the child become more and more noticeable and the strength of the muscles and sinews grows. The mother’s urge to move increases, and she should certainly give in to it. Because the earth phase is responsible for the transformation and digestion of food, the text pays the greatest attention to diet in the fifth and sixth month. The recommendations are hereby very similar: All five flavors should be taken account of, especially sweet and well-tasting foods, but not in excessively large amounts. A new feature for the time associated with the stomach is the emphasis on a yang– and qi-boosting diet, which can to a large extent consist of meat. Game is especially recommended for the pregnant woman during this time. Such a diet nourishes the strength of the fetus and secures the back and spine.

For mother and child, this protein-rich diet is usually easy to digest since the stomach channel supplies the child in this month. At this time, do not sedate the stomach channel. Because the stomach governs the mouth and eyes, the Chinese classics assume that the mouth and eyes of the fetus are completed in the period of the sixth month. According to Sun Simiao, disorders of the earth phase manifest in very complex symptoms, with pathogenic fullness of the center (flatulence, feeling of fullness, abdominal pain) in the foreground.

“In the sixth month of pregnancy, for sudden stirring [of the fetus], alternating [aversion to] cold and heat [effusion], intestinal fullness in the abdomen, swelling of the body, fright and fear, … sudden presence of vaginal discharge, abdominal pain as if she were going into labor; and vexation and pain in the extremities, [the patient] should take Mai Men Dong Tang (Ophiopogon Decoction).”⁶

The symptoms introduced here are, however, only a small selection among the many possible physical signs of disharmony. The mother’s ability to “digest” and hold a pregnancy becomes especially apparent in this middle period. Thus, the slippery pulse that is typical in pregnancy, for example, should be detectable during this earth phase at the latest. The earth as the symbol of maternity can manifest itself during this time in increased conflicts, dreams, or encounters with one’s own mother. The theme of the earth phase is community, and pregnant women should therefore particularly enjoy spending time in the circle of their family and friends during this time—it saves them from worrying and fretting.

Seventh and Eighth Month—The Metal Phase

The metal phase entails clarity, structure, and processes of letting go and separating. The general theme is order in all affairs, to make space for the newborn, and the beginning preparation for the separation of mother and child. During this time, behavioral advice focuses less on diet, but more on promoting external mobility and internal clarity.

“In the eighth month of pregnancy, for wind or cold strike, offenses against prohibitions, pain all over the body, abruptly alternating [aversion to] cold and heat [effusion], stirring fetus, constant problems with dizziness and headaches, coldness below and around the navel, frequent urination of a white substance like rice juice or a green or yellow substance, or accompanied by cold shivering, bitter cold and pain in the lumbus and back, or blurred vision, Shao Yao Tang (White Peony Decoction) is the governing prescription.”6

These descriptions as well are rooted in the differentiation between external pathogenic climate factors and internal emotional triggers. The pregnant woman as well as the practitioner should therefore pay attention to both of these. Grieving or separation processes are not uncommon themes during this time, and pregnant women who are affected by such problems require especially intensive support. The metal phase corresponds to the quality of the father. The father of the pregnant woman, as well as the father of the child, can require increased attention. Internal and external house-cleaning and organizing can free a lot of energy for the pregnant couple during this time.

The seventh and eighth months offer a good opportunity in the care of pregnant women to look back and evaluate the previously experienced phases. Hereby, we can once again notice anomalies that have previously escaped the practitioner’s attention. For example, if we notice that the pregnant woman is always delayed in attaining the new quality, we can carefully predict that the time of delivery is also more likely to be late than early. Every woman has her own sensitivities and individual dynamics, which reveal themselves during the pregnancy and make prognoses for the birth experience and the lying-in period possible.

Ninth and 10th Month—The Water Phase

As the phase of winter, the water phase is associated with deep collection and inner stillness, in which spring (the birth) can prepare itself. The pregnant woman should experience the quality of inner centeredness in this time because it puts her in touch with her strength and gives her a relaxed calmness for the impending delivery.

“In the ninth month of pregnancy, for suddenly contracted diarrhea, abdominal fullness with a sensation of suspension and tension, fetus surging up against the heart, lumbar and back pain with inability to turn or bend, and shortness of breath, Ban Xia Tang (Pinellia Decoction) [is the governing prescription].6

In addition to the already known signs of a disturbance, this quotation vividly describes the immediate effect of the maternal emotion—in the water phase this is fear—on the child. Cultivate peacefulness, confidence, and composure.

In the 10th month, the fetus receives the qi of heaven and earth in the dan tian, as a result of which the joints close and the shen is fully present. The child is supplied by the bladder channel. Now the only thing left to do is to await the right moment for the birth, because in the Chinese perspective the child’s dao determines the hour of birth. You should therefore refrain from urging the woman on.

“The mother should take ‘fetus-lubricating medicines,’ but only after she has entered the month [of childbirth]. Dan Shen Gao (Salvia Paste) is a prescription for nourishing the fetus, to be taken in the month of delivery, lubricating the fetus and easing childbirth.”⁶

The best preparation for birth is for the mother to consciously live through the water phase. In these last weeks, when the child develops only slightly but must grow all the more, it is gathering jing, which is extremely important for a strong state of health. From this perspective, carrying the fetus for up to 14 days past the due date can make sense and can be affirmed by the pregnant woman without any internal stress, because every day nurtures the water of the child, its kidney essence, and its primal sense of trust. When the child, the mother, and the father go into delivery strengthened in this way, the chance of delivering without obstetrical intervention is good.

Even though the successful completion of a pregnancy signifies the completion of the practitioner’s task of treating a couple who wants a child, we should mention here that the lying-in period deserves special attention. Already valid for women in childbed without complications during conception and pregnancy, this is all the more true for women with a less robust constitution. Observing the advice of TCM regarding behavior and diet during this unique time of regeneration can lay the foundations for an unproblematic menopause later on.¹

Support in Failed Fertility Treatment

The previous chapter was intended to show how Sun Simiao’s “pregnancy calendar” might offer approaches for stabilizing and supporting an at-risk pregnancy. Nevertheless, the unpredictability of childbearing sometimes means that even the most outstanding knowledge of TCM and the newest methods of reproductive medicine fail to deliver the desired result. This happens, for example, when several IVF or ICSI attempts remained unsuccessful or when several miscarriages or extrauterine pregnancies occurred. If a pregnant woman loses her child and is unable to complete the cycle of the above-mentioned “seasons,” this sad situation also requires us to pay attention to the cycle of the five phases—both in the task of grieving and with regard to the question when she should attempt to conceive again.

When Can the Woman Become Pregnant Again?

Nevertheless, when we consider pregnancy from the angle of TCM, we realize two things: first, the first two phases are associated with yang and the second two phases with yin. That is, the processes taking place inside the woman become increasingly profound and internal. Second, there is the division of pregnancy into trimesters, associated with the three treasures shen, qi, and jing:8

• In the first trimester, the pregnancy is governed by shen. The child is influenced in its creation and development more by the heavenly (yang) than by the earthly (yin) powers. The main force of growth in the child operates in the upper burner, hence the head is oversized in proportion to the rest of the body.
  
• The second and middle trimester of the pregnancy is associated with qi. The organs develop.
  
• The last and third trimester stands for the jing and thereby for the deepest and innermost layer in the human body. The child is completed and solid and gathers its constitutional strength out of the mother’s jing.

This illustrates how significant the time of a miscarriage or premature birth is for the question of another pregnancy. With an increasing length of pregnancy, the damage and exhaustion of the mother’s resources become more and more pronounced and the regeneration period becomes longer and longer.

In light of the succession of the phases of correlative thinking, we must moreover observe the following: a started cycle must be finished in all cases, even if the child was lost already in the first few weeks of pregnancy. We could understand this in such a way that the child’s dao continues to affect the mother’s body up to the intended time of its birth.

An example of this: a woman who became pregnant in the beginning of May loses her child in the middle of June (in her eighth week). According to doctor’s orders, she waits 3 months and again becomes pregnant in the beginning of October. The due date of her first child was January 22. At this time, the woman will be in the transition period from fire to earth in her second pregnancy, that is, in her 17th or 18th week. Because the cycle of the first child is still affecting her, we should be prepared for a—albeit weakened—“birth impulse.” This new knowledge allows us to understand complaints or even bleeding around this critical time in a new light and relieve them gently, in order to allow the second pregnancy to successfully run its course.

If another attempted conception does not succeed or the developing fetus is lost, we must then clarify additional realistic treatment expectations that the couple can still have of TCM in this situation. As part of this process of clarification, we reflect on the effects of the fertility treatment on the couple’s relationship and sexuality whilst taking into account the particular familial and professional circumstances.

Fertility Treatment and Couple Dynamics

“Everybody knows that we want to have a child but cannot do it”—the feeling of failure on this elemental level of existence leaves deep traces in the self-confidence of both partners. The failure to meet the expectations of one’s own parents, whether putative or real, to maintain the succession of generations, the expressed or implied accusation of social selfishness—all this often causes unbearable pressure and the prospect of a complete loss of perspective after the personal catastrophe of childlessness.

Alternatives—Adoption and Accepted Childlessness