Female Infertility & Reproductive Gynaecology
This landmark book is the most complete presentation of the integrated Chinese and biomedical treatment of infertility and reproductive gynaecology in the English language. Although primarily devoted to Chinese herbal medicine, the comprehensive discussions of every aspect of infertility, and the acupuncture protocols given for every pattern, will benefit every practitioner working in the field.
The lead author, Professor Yuning Wu, is principal doctor and Professor of Integrated Chinese and Western Medicine at the Beijing Hospital of Traditional Chinese Medicine. She is a leading fertility specialist in China. Infertility is a field in which integration of the two medicines is especially effective, and Dr. Wu demonstrates throughout this deeply clinical book the strengths of this dual approach.
Foreword by Peter Deadman
Preface by Professor Yuning Wu
Preface by Celine Leonard
Chapter One: How to use this book
Chapter Two: Basic theories of Chinese medicine gynaecology and infertility
Chapter Three: Core strategies for treating female infertility
Part One: Disorders of menstruation
Chapter Four: Regulating the period using Tiao Jing Fang (Regulate the Menses Formula) Chapter Five: Disorders of timing - short cycles
Chapter Six: Disorders of timing - long cycles
Chapter Seven: Disorders of timing - irregular cycles
Chapter Eight: Disorders of bleeding - menorrhagia
Chapter Nine: Disorders of bleeding - scanty menstruation
Chapter Ten: Disorders of bleeding - prolonged menstruation
Chapter Eleven: Disorders of bleeding - midcycle bleeding
Chapter Twelve: Disorders of bleeding - abnormal uterine bleeding (beng lou)
Chapter Thirteen: Miscellaneous disorders - dysmenorrhoea
Chapter Fourteen: Miscellaneous disorders - premenstrual syndrome
Part Two: Gynaecology and infertility
Chapter Fifteen: Amenorrhoea and anorexia nervosa
Chapter Sixteen: Polycystic ovary syndrome
Chapter Seventeen: Myoma (fibroids)
Chapter Eighteen: Ovarian cysts
Chapter Nineteen: Endometriosis and adenomyosis
Chapter Twenty: Luteal phase defect
Chapter Twenty-One: Luteinised unruptured follicle syndrome
Chapter Twenty-Two: Hyperprolactinaemia
Chapter Twenty-Three: Tubal infertility
Chapter Twenty-Four: Diminished ovarian reserve and premature ovarian failure
Chapter Twenty-Five: Recurrent miscarriage
Chapter Twenty-Six: Immune infertility and immune recurrent miscarriage
Chapter Twenty-Seven: Using Chinese medicine to support assisted reproductive technology treatment
Chapter Twenty-Eight: Ovarian hyper-stimulation syndrome
Chapter Twenty-Nine: Pregnancy care Appendices
Appendix 1: Animal and endangered products and herb cautions
Appendix 2: Dispensing Chinese herbal medicines
Appendix 3: Basic fertility and pregnancy blood test values (with US/European conversions) and explanation of abbreviations
Appendix 4: Classical acupuncture prescriptions for gynaecology and infertility
Reviewed by Caroline Radice, DACM, LAc., in The Journal of Chinese Medicine
When I was asked to review Female Infertility & Reproductive Gynaecology: A Comprehensive Clinical Manual of Integrated Chinese Medicine and Biomedicine, my initial thought was “finally, someone wrote the book!” Over my 25 years of practice and teaching, I have been frequently asked by students for a complete reference text for herbalists treating infertility and it has arrived. Yuning Wu, Celine Leonard and Michael Haeberle have produced a definitive source for practitioners that clearly outlines how we should think about diagnosing and treating the complicated clinical presentations that manifest in women struggling with infertility.
A five-year and nearly 500-page editing project of Peter Deadman, Inga Heese, and Daniel Maxwell, I found it completely accessible with meticulous detail and depth. Organized similarly to my own lineage in Traditional Chinese Medicine and consistent with my teaching and practice, the text in Part One outlines disorders of menstruation: where all gynecology begins. Regulate the cycle first, and you are well on the way to a successful outcome. Principal Doctor and Professor of Integrated Chinese and Western Medicine at the Beijing Hospital of Traditional Chinese Medicine, fertility expert Yuning Wu thoroughly discusses basic theory and fundamental strategies as guidelines to treatment. Once timing, bleeding, and pain disorders are addressed, integrated assessments of biomedically defined diseases, starting with those most commonly seen in the infertile woman such as polycystic ovarian syndrome, myomas, and endometriosis are carefully outlined in Part Two of the text. I was delighted to see extensive discussion on complex disorders associated with infertility and miscarriage as well as early pregnancy care. Each disease includes comprehensive discourse by Dr Michael Haeberle, a reproductive endocrinologist based in Zurich, Switzerland on biomedical understanding, evaluation, and standard treatments of each condition far beyond basic discussions of In Vitro Fertilization (IVF).
My appreciation for the clarity of the presentations on syndrome differentiation cannot be overemphasized. Dr. Wu walks through the basic patterns, discusses the most commonly used herbal formulas, and highlights appropriate modifications with precise and logical progression from diagnosis to treatment principles to formula with respectful homage paid to the source text of each prescription. A wonderful detail is the listing of individual herbal properties with each modification, such as “add pungent-sweet-warm Ba Ji Tian (Morindae officinalis Radix) 10g for Kidney Yang deficient lower back pain.” The discussions include helpfully outlined clinical notes to emphasize a strategy to use or avoid, such as using caution when prescribing blood invigorating herbs in the luteal phase or avoiding the herb Bu Gu Zhi (Psoraleae Fructus) when a woman is actively trying to conceive. Illustrative case studies from the clinics of Dr Wu, Celine Leonard, and Esther Denz accompany every syndrome to provide a real world application of each chapter discussion. Although primarily an herbal text, acupuncture strategies are included with each chapter and case with guidance not only to point selection and timing, but also technique.
What is truly unique about this text is how well it weaves Chinese medicine and biomedical evaluation and treatment strategies. When an infertility patient presents clinically, she may be either brand new or very familiar with the language of Chinese Medicine. Unexperienced patients here in the West typically discuss their presentation using biomedical terms, so it is incumbent on the practitioner to be familiar with the terminology and assessments of biomedicine and Assisted Reproduction Techniques (ART). New patients may not be familiar with what a “normal” menstrual cycle should look like, nor have terminology to discuss it. My initial evaluations of fertility patients typically include education and self-care techniques including Basal Body Temperature (BBT) and fertility awareness, descriptions of which are also included in the text for each disease presentation. These can be useful adjunct tools to help patients feel more proactive in their care and see objective progress.
Patients who are further along in the fertility journey may present with a long history of ART interventions and are involuntary experts in their own reproductive health. Practitioners in possession of only a cursory understanding of biomedical diagnoses, presentations, and treatments will not instill confidence in patients seeking care in an often very vulnerable population. An experienced patient will discuss lab results, interventions and medication usage that all have effects with which the practitioner should be familiar. Even though these don’t necessarily determine the course of evaluation and treatment with Chinese herbal medicine as we will diagnose using our own tools, it is important to know how to work with this information, particularly when making appropriate referrals and setting treatment expectations.
For example, having integrated knowledge of a disease like endometriosis is essential for a few reasons I see clinically. First, the diagnosis can be casually used by patients who have suspected endometriosis based on a history of dysmenorrhea, dyspareunia or infertility, but may be unaware that this can only be officially diagnosed via laparoscopy. If they have not had any direct visualization, but there is a strong suspicion, a referral might be indicated and such intervention will delay attempts to conceive. Other times, this is unnecessary. Additionally, treatment of complex diseases like endometriosis will often require several months of addressing blood stasis with herbs when the patient is specifically advised to avoid conception. Most women desiring pregnancy do not want to delay, but informing them that the obstacles to their success may require treatments that temporarily postpone attempts in order to be more successful are usually met with agreement if presented with a well-informed approach. Dr Wu discusses no less than five main patterns for treatment of endometriosis with Chinese herbal medicine and the most common formulas, but also dozens of modifications for patients with different types of pain, bleeding and other systemic symptoms with commentary on dosing and accessibility of specific substances she most often uses clinically. These formulas are presented based on timing before, during and after the period to optimize treatment success and include not only internal herbs, but external herbal compresses and retention enemas as additional treatment options. She then outlines how to progress from active treatment to directly promoting fertility once symptoms have been alleviated. This is but one example of how Dr Wu uses Chinese Medicine specifically to fit the individual, not the disease, yet understands the complexity of treating such a serious obstacle to fertility.
Another complicated disease seen frequently among women with infertility, polycystic ovarian syndrome (PCOS), presents with variations on a typical pattern. The criteria for this diagnosis are not consistent among all women with PCOS and there are many atypical patterns in Chinese medicine beyond the simple classic one presented in many texts. Some women are unaware that they may have PCOS and they may not have had an evaluation with a gynecologist prior to visiting your clinic, so being able to recognize all the patterns will help you make appropriate informed referrals if necessary, as combining with medication is sometimes indicated in poor responders. Here again, Dr Wu outlines the Chinese medicine presentations followed by thorough biomedical definitions and evaluations by Dr Haeberle. Common treatments for both are detailed, along with prognosis and expectations from care for each of these methods. The details of each pattern and sub pattern are discussed with attention and nuance so refreshingly different from many simple herbal protocol based approaches and highlight the real capability of Chinese herbal medicine to treat complex infertility. There are also important cautions featured as with other infertility patterns that emphasize the limitations of both medicines and when to refer or combine medical approaches, such as in a patient with a more severe presentation.
Contemporary biomedical treatments for infertility progress so rapidly that it is important to stay current with the ever-changing approaches, but also the evolving understanding of what has been often inexplicable, as in the not uncommon presentation of “unexplained infertility.” These patients are often very frustrated as they have nothing specifically identified they can address in order to “fix” them. Chinese medicine can very often be successful for these patients as it can be simply a matter of adjusting more subtle imbalances, an area where herbal medicine excels. Dr Wu also presents lesser discussed biomedical syndromes, such as Luteinized Unruptured Follicle Syndrome (LUFS), common in these patients diagnosed with unexplained fertility that may occur in up to 23% of otherwise normal menstrual cycles, according to the text. This condition, where the follicle does not rupture, is not well understood in biomedicine and is believed to be more common in infertile women than even endometriosis or pelvic inflammatory disease (PID). As with other syndromes, she details how this can be evaluated and differentiated with Chinese medicine and BBT and discusses how to fine tune treatment to promote successful ovulation without unwanted and potentially dangerous side effects of hormones such as hyperstimulation, seen more often in women who make but don’t release follicles like in LUFS and PCOS.
Also rarely discussed in any detail are some very complicated and difficult to treat syndromes such as hyperprolactinemia, diminished ovarian reserve, premature ovarian failure, and tubal infertility. Comprehensive explanations, prognoses, and references bring poorly understood and often left-for-untreatable pathologies options for care that are realistic and well informed. Drs Wu and Haeberle discuss when it is appropriate to consider surgery and hormones and when patients are likely to not be successful in their attempts to conceive naturally.
Beyond getting pregnant, there are also comprehensive chapters on staying pregnant successfully for patients with immune and recurrent miscarriage and ectopic pregnancy history. Not just complex, these syndromes can be life threatening if not treated timely or properly. As with all the syndromes contributing to infertility, while extensively knowledgeable about factors that contribute to these pathologies, such as sexually transmitted and pelvic infections, Dr Wu is firmly grounded in evaluating and treating according to Chinese medicine pattern differentiation in each and every case. She can also speak extensively on biochemical actions of Chinese herbs according to pharmacological research and how supportive these findings are of her traditional approach.
Later chapters discuss in great detail how to integrate treatment for a patient undergoing intra uterine insemination (IUI) or in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI). She describes her six stages of treatment to accompany IVF and how to adapt treatment to match the hormone protocol. These are consistent with the stages before, during and after egg maturation and retrieval and specify how and when to warm, move, or tonify and what herbs to specifically to use as well as to avoid. This is the most detail I have ever seen in a Chinese herbal medicine text designed and discussed with such clarity and specificity in combined IVF therapies. They also include a chapter on ovarian hyperstimulation syndrome (OHSS), though while not common, can be very dangerous. Being able to identify patients at risk for OHSS and recognize a patient who may be experiencing this during a stimulation phase of an IVF cycle can literally save a life. As Chinese medicine practitioners, we will be more often helpful in the recovery phases of OHSS as she outlines in her differentiation.
The text closes with a chapter on caring for women in early pregnancy and specific herbal and acupuncture cautions during pregnancy, which should always be respected. Appendices that follow include endangered species and contraindicated herbs, glossary of medical terms and abbreviations, blood test values, classic acupuncture prescriptions for fertility, and methods of dispensing Chinese herbs.
As a long time practitioner and teacher of Chinese herbal medicine with extensive experience in the treatment of female infertility, I am delighted to finally see a comprehensive integrated reference text available to practitioners to advance their knowledge and treatment options. According to the Centers for Disease Control and Prevention, about 1 in 10 women in the United States ages 15–44 have difficulty becoming or staying pregnant. This population deserves well informed experienced practitioners of Chinese and biomedicine and this represents an excellent source text for using these medicines together. I look forward to referring this resource to colleagues and students.