Jane Lyttleton

This article presents a case study of a woman in her 30s suffering from a number of chronic disorders including headaches, back pain and depression as well as erratic ovulation and possible early menopause. Treatment involved both acupuncture and Chinese herbal medicine and focussed initially on her general health and on regulating her menstrual cycle with specific fertility treatments commencing two years later. The case study highlights many of the sorts of questions which practitioners have to deal with in trying to help women seeking treatment to aid fertility, and provides a good example of how useful the information from basal body temperature (BBT) charts can be and how it can influence the course of treatment. 

This is one of the more complex and challenging cases of infertility that I have come across, not simply because Mary ovulated very erratically and her doctors said she had 'premature menopause' or 'resistant ovary syndrome', but also because the poor woman had so many other clinical conditions to contend with. The fact that she succeeded in having a baby speaks volumes about her courage and persistence in the face of almost constant distressing physical symptoms. I present the case here because it highlights many of the sorts of questions we have to deal with as practitioners trying to help patients who are extremely stressed and distressed by their failure to fall pregnant and who can understandably become obsessed by the pursuit of pregnancy, especially when their ovaries are not working well and menopau0se is imminent. This case also provides a good example of how useful the information from basal body temperature (BBT) charts can be and, in fact, can influence strongly the direction of the course of treatment. Of course, not all infertility cases are as complex as this one, but in the West many are not straightforward and it is the rule rather than the exception that women seeking treatment to aid fertility will have had or will be considering many sorts of interventionist treatment which will likely add to the many layers of the TCM diagnosis and consequently to the approach to treatment.

Mary was 33 years old when she first sought treatment for the following chronic disorders. Headaches; these were a daily or weekly occurrence. The milder ones she treated with panadeine forte and ergotamine or inderal. The more severe ones were treated in hospital with injections of pethidine. Back pain; she experienced constant pain especially in the mid back, largely structural in origin and required very regular osteopathic treatment. Depression; she took anti-depressives which helped her in coping on a day-to-day basis, but she still felt suicidal at times, especially before a period. Insomnia; her sleep was usually restless and dream disturbed and she frequently relied on sleeping pills. Back pain often woke her at night too. Periods/amenorrhoea; her cycle had always been erratic, with the periods sometimes disappearing for 6 months at a time. She was concerned for her fertility because of this and because of her mother's early menopause (by 40 years of age). Such a tendency may be inherited.

Initially, treatment focussed on her general health and regulating the period cycle. Treatment for fertility began in earnest two years later after she had married and had not fallen pregnant after 12 months of using no contraception. The signs and symptoms of menopause were becoming increasingly apparent.

Relevant clinical symptoms:
-     parietal and vertex headaches with flushed face
-     frequent anxiety and agitation, irritability, depression            
-     sleeplessness
-     feeling hot and thirsty
-     irregular and long menstrual cycles
-     scanty menstrual flow, bright red blood, no clots, no pain, stop/start flow
-     severe PMS, feeling edgy or if severe, suicidal
-     fertile mucus sometimes observed. Often no vaginal secretions at all
Pulse; thready and rapid. Tongue; red and peeled, especially on the sides and the tip. BBT charts; Mary began to record her basal temperature when she began to think about trying to fall pregnant. You can see all her charts in the section following.

Modern TCM uses the shape of BBT charts to aid in the diagnosis of infertility and menstrual disorders related to hormonal imbalances. Specifically, BBT charts can help us discern infertility related to kidney yang or yin deficiency, spleen deficiency or heart and liver fire. They can be especially useful if there are few clinical symptoms and a diagnosis is not clear. However, Mary had plenty of clinical symptoms and her diagnosis was clear; we used her charts to check progress with the treatment.

Diagnosis
Here we have a picture of serious internal heat affecting the liver and heart. Initially the heat may have been of a shi nature (caused by external stress) but now there are signs of yin deficiency and the heat will be of a xu nature. In addition to giving rise to liver fire (headaches, flushing, irritability) and heart fire (insomnia, agitation, anxiety) the yin deficiency is starting to cause dryness (vaginal dryness and thirst) and blood deficiency (scanty periods). A vicious circle is created as the internal heat dries the yin and the blood which of course allows more internal heat to manifest. The more the heat disturbs the shen or the mind the harder it is for yin to recover and grow. To manage the headaches and the insomnia, clearly the heat in the liver and the heart had to be cooled and liver and heart yin had to be strengthened. To address the long and irregular cycles the kidney yin and the liver blood had to be tonified. Particularly relevant in cases of ovulation disorders is the state of the heart/shen. Even when the kidney yin is adequate, heart fire or heart qi stagnation can prevent ovulation.

Treatment Principles:
-     sedate liver fire and yang
-     calm shen/heart fire
-     tonify kidney yin
-     tonify liver blood

Treatment to sedate liver yang and calm heart fire was fairly straightforward. The following is one example of the sort of prescription used. The herbs had some good effects as did the acupuncture (see below) which was applied at the times Mary could attend the clinic.

Gou qi zi (Fructus Lycii) 10
Ju hua (Flos Chrysanthemi) 5
Sang ji sheng (Ramulus Loranthi) 10
Shan yu ruo (Fructus Corni Officinalis) 10
Bai shao (Radix Paeoniae Lactiflora) 10
Chuan xiong (Radix Ligustici Walichii) 10
Gou teng (Ramulus et Uncus Uncariae) 10
He huan pi (Cortex Albizziae) 12
Suan zao ren (Semen Zizyphi Spinosae) 18
Huang lian (Rhizoma Coptis) 10
Mu li (Concha Ostreae) 20
Long gu (Os Stegodontis) 20

Gou teng and huang lian are used here to clear liver and heart fire respectively. Gou qi zi and ju hua tonify liver yin to prevent yang rising. He huan pi, suan zao ren, mu li and long gu all calm the mind. Bai shao supports liver blood while chuan xiong regulates the blood. Sang ji sheng clears wind at the same time as tonifying liver and kidney. Shan yu rou also tonifies liver and kidney. As the sleep improved the doses of the sedative herbs and heat clearing herbs were reduced and eventually mu li and long gu were removed.

Acupuncture points used to treat the headaches and the insomnia included GB 20 feng chi, LI 4 he gu, Liv 8 qu quan, P 7 da ling, Ht 7 shen men, Ht 8 shao fu, K 3 tai xi, Sp 6 san yin jiao, yin tang.

Neither the headaches nor the insomnia were cured outright, however; they were manifestations of such a complex psychological, physiological and structural picture that that would be unlikely in the short term. Nevertheless, symptoms definitely became more manageable and this was also helped in no small way by the development of a supportive relationship in Mary's life.

The problem of the reluctant ovaries persisted - her periods coming every six or seven weeks and sometimes after only three weeks, these latter probably being anovulatory cycles. Once she started recording basal body temperature charts it was evident that Mary was ovulating only some of the time, that she had a menstrual cycle and, given the shape of her BBT charts, we could say that even these ovulations were not necessarily good enough for conception and pregnancy, i.e. they did not produce the necessary levels of hormones for implantation and growth of the foetus. Charts 1,2,3 and 4 (corresponding to Cycles 1,2,3 and 4) are the temperature charts Mary recorded when she first started trying to fall pregnant. She began taking herbs to treat infertility in Cycle 4 and infertility drugs the cycle after that (Cycle 5).

Shortly after Mary and her partner formally married (and during Cycle 4) we got some rather grim news. Her gynaecologist pronounced that Mary (at age 35) had a premature menopause. This was based on the following signs and symptoms:

-     erratic periods
-     flushing that she experienced increasingly even in the absence of headaches
-     extreme vaginal dryness
-     repeated blood tests showed high FSH and LH levels (i.e. in the range found after menopause). FSH (follicle stimulating hormone) and LH (luteinizing hormone) are hormones produced by the pituitary gland and which act on the ovaries. When the ovaries start to shut down they do not react to the hormones and the pituitary produces more and more FSH and LH to try and provoke a response.

As we mentioned earlier, Mary's mother had also had a premature menopause and often such patterns are inherited.

The gynaecologist spelled out to Mary and her husband the options for having children - they were pretty limited. Mary was advised to start thinking about finding a source of donor eggs since her own could no longer be relied upon. Since Sydney fertility clinics do not keep stores of eggs for donation it would be up to Mary and her husband to find an appropriate donor. The donor, who obviously must be young and healthy, would need to take fertility drugs by injection and undergo ultrasound and blood test tracking until the eggs were mature enough for harvesting. At that point the woman donating the eggs would go into the surgery and, while sedated, would have the eggs removed from her ovaries with a delicate instrument inserted through the vaginal wall. It was a lot to ask even of a best friend. Even if they were successful in finding such a donor then there would be the anxious moments of waiting to see if Mary's husband's sperm (which, by the way, was quite adequate in terms of numbers and motility) would fertilise the eggs, if any of them would then develop into embryos and finally if any of them would implant in Mary's uterus and establish a successful pregnancy. The chances were about 15%. Then there was adoption or fostering.

They were understandably reluctant to pursue donors or adoption immediately although it was not exluded as a future option. They asked me if anything else could be tried in the face of Mary's premature menopause. Because of Mary's likely genetic programming for an early menopause I did not hold out much hope but I did have a few more things up my sleeve to try than did the gynaecologist at that point.

I chose to use an approach which I had learned from Dr Xia, the director of the Gynaecology Department in Nanjing TCM hospital. This treatment was used in that hospital in cases of ovary shut down (amenorrhoea) due to heart and liver fire drying the yin and the blood. Basically, it involved purging empty heat in an attempt to recover and reactivate what yin is left in the reproductive system.

Da huang (Rhizoma Rhei) 10 ( boil 10 mins only)
Bo he (Herba Menthae Arvensis) 10 (boil 5 mins only)
Lian qiao (Fructus Forsythiae) 10
Sheng di (Radix Rehmanniae) 12
Shan yao (Rhizoma Dioscoreae Oppositae) 10
Shan yu rou (Fructus Corni Officinalis) 10
Dang gui (Radix Angelicae Sinensis) 10
Bai shao (Radix Paeoniae Lactiflora) 10
Dan pi (Cortex Radicis Paeoniae Suffructicosae) 10
Dan shen (Radix Salviae Miltiorrhizae)10
Suan zao ren (Semen Zizyphi Spinosae) 18

Da huang, bo he and lian qiao are the main ingredients to clear fire from the heart. Da huang promotes bowel movements to clear heat and Mary was warned that she may get diarrhoea. The rest of the herbs attempt to build the blood and, at the same time cool it. The final two herbs are used to keep the mind calm.

The herbs seemed to do the trick - she immediately started sleeping better. The flushing and her thirst subsided and she felt emotionally much calmer. More significantly, the vaginal dryness improved and secretions returned quite quickly. After two days of the purging herbs she began to get diarrhoea and we switched to another treatment (based on Mai Wei Di Huang Tang) to quickly capture and maintain the ground gained.

Shan yao (Rhizoma Dioscoreae Oppositae) 10
Shu di (Radix Rehmanniae Preparatae) 10
Shan yu rou (Fructus Corni Officianalis) 10
Mai dong (Radix Ophiopogonis) 10
Dan pi (Cortex Radicis Paeoniae Suffructicosae) 10
Dan shen (Radix Salviae Miltiorrhizae) 10
Fu ling (Slerotium Poriae)12
Yi yi ren (Semen Coicis) 15
Wu wei zi (Fructus Schisandrae) 10
Suan zao ren (Seman Zizyphae Spinosae) 18

You will recognise that this is the famous yin tonic 'Liu Wei Di Huang Tang', (with yi yi ren instead of ze xie which was considered too heating) plus an extra yin tonic (mai dong) and something to keep in the precious and elusive essence (wu wei zi) to make the formula 'Mai Wei Di Huang Tang''. Something to move the blood (dan shen) was added to encourage movement in the ovaries and uterus and calm the mind. Suan zao ren also calms the mind.

With these herbs the vaginal discharge began to thicken and get stretchy (i.e. she started producing fertile mucus) and her libido increased.

Because Mary was feeling that something had changed markedly, she persuaded her gynaecologist to take another blood test. The result of this was so different to those taken previously (the levels of FSH were now in the normal range for the mid-cycle of an ovulatory cycle) that the diagnosis of premature menopause was retracted. Her oestrogen levels, however, were still low and her LH was still a little elevated. It appeared that more nourishment of the yin and blood was needed to bring about an ovulation and a period. The following herbs were used, incorporating principles of building, cooling and moving the blood and calming the mind. By keeping the mind calm it was hoped the yin could build too.

Shu di (Radix Rehmanniae Preparatae) 12
Sheng di (Radix Rehmanniae) 10
Bai shao (Radix Paeoniae Lactiflora) 10
Chi shao (Radix Paeoniae Rubrae) 10
Shan yao (Rhizoma Dioscoreae Oppositae) 10
Shan yu rou (Fructus Corni Officianalis) 10
Dan shen (Radix Salviae Miltiorrhizae) 10
Fu ling (Sclerotium Pariae) 10
Yi yi ren (Semen Coicis) 15
Han lian cao (Herba Ecliptrae) 10
Suan zao ren (Seman Zizyphae Spinosae) 18
Huang lian (Rhizoma Coptis) 6

After three weeks on this formula she had her first period in 11 weeks (Chart 4). At this point the gynaecologist persuaded Mary to start a regime of clomiphene (Clomid).

This may not have been the best tack to take, however. She and her husband were desperate to try anything and everything. I feel there is often little to be achieved by discouraging the use of medical drugs in such a case where the patients have been strongly advised to take them by a specialist and they believe them to be the best treatment. In this delicate situation and time, it is best to be encouraging and supportive of whatever decisions the couple make providing it is an educated one. Later on, as you will see, when the patient and I had plenty of evidence of the effects of the Chinese herbs and the Clomid on her cycle and body, I was more able to suggest that a direction other than that recommended by the specialist was preferable. I should add that quite often in this work I also recommend the use of fertility drugs and/or artificial reproductive techniques like IVF when there is not time for Chinese medicine to work or I think that modern scientific medicine will achieve a better result. Every case and situation is different; it is not only the clinical details that need to be considered but also the personality and belief framework of the woman and her husband. Clomid can be a very useful infertility drug, especially for women who do not ovulate very well. From that point of view Mary seemed a natural candidate and her doctor prescribed what every other specialist in his position would have prescribed.

However, TCM affords us another perspective. Clomid is considered a 'heating' drug and is very effective in helping fertility in cases where there is kidney yang deficiency. Clinically, infertility related to kidney yang deficiency is often complicated with kidney yin deficiency. And when there is pronounced yin deficiency and internal empty heat, then taking something as heating and drying as clomiphene presents more of a risk. At best, in such cases, it produces uncomfortable side effects and at worst it burns out the ovaries so that they stop functioning altogether.

Clomiphene regime
Clomiphene is given from day 3 - 7 or day 5 - 9 of the menstrual cycle. The starting dose is 50mg/day although this can be raised progressively in subsequent cycles to as much as 200mg/day if necessary. Most patients ovulate in response to 50 or 100mg/day and 80% of conceptions occur in the first three ovulatory cycles. If the clomiphene is successful it will induce ovulation 10 - 15 days after the first day it is taken. Sometimes the stimulation of the ovaries causes some enlargement and discomfort. However, this subsides in two to four weeks. From the Chinese medicine point of view more worrying are the yin damaging effects of the drug viz. the hot flushes, the drying up of the fertile mucus, the thinning of the endometrium and the irritability. In sensitive individuals the liver and kidney yin are at risk. Mary certainly fitted into this category but, fortunately, she seemed to cope with the clomiphene quite well. Not so the next drug, hMG, which, as you will see, brought everything to a complete stop.

Side effects of Clomid:
-    ovarian enlargement (>6cm)
-    abdominal discomfort
-    flushing
-    irritability, mood disturbances
-    lack of fertile mucus, vaginal dryness
-    visual symptoms (blurring, spots or flashes)
-    headaches
-    thinning of the endometrium
-    breast tenderness
-    nausea and/or vomiting

Because Mary was probably on the verge of menopause, and the chances of her falling pregnant were slim, she was prepared to try all therapies offered, even drugs with potential side effects. And so it fell to me to use herbs and acupuncture to support the action of the drug and attempt to protect the yin from potentially damaging side effects. This we did by using formulae with an emphasis on clearing heart fire and tonifying the yin. It is instructive to follow closely what happened as she followed the drug regime because it demonstrates clearly some typical clinical reactions, ones that you will come across frequently in an infertility clinic in the West.

Different formulae were used at different times in Mary's cycle and in response to different events and symptoms at the time. However, because she took some 200 packets of herbs over the period of time she was trying to fall pregnant (12 months) it is impossible to include all the prescriptions here.

Here are presented typical formulae that she used at different times of her cycle. These basic formulae would be subtly altered to suit the immediate signs and symptoms, e.g. with severe back pain or headaches other herbs were added as were acupuncture points specific to the pain. Similarly, insomnia or agitation required more sedative herbs. Sometimes particular side effects of the drugs would dictate changes to treatment, e.g. with abdomen swelling and pain more qi and fluid regulating herbs were used and local abdomen acupuncture points. In the cycles when there appeared to be no sign of ovulation Mary took Formula A or variations thereof. The treatment was based on the changes in yin, yang, qi and blood that happen during a menstrual cycle. For the first phase of a cycle the emphasis was on encouraging the growth of yin and blood. Yin tonics aid the development of a follicle in the ovary until the egg it contains is large and ripe enough to be released.

Blood tonics encourage the development of the lining of the uterus as it thickens and proliferates. As the yin becomes more plentiful the cervix produces the fertile mucus which many women notice around mid cycle. As ovulation approaches and the abundant yin gives rise to yang, we add some yang herbs in small doses. At ovulation the principle behind treatment is to encourage movement of the egg from the ovary to the Fallopian tube and hence to the uterus. It is important to keep the shen calm at this time too. After ovulation it is important that the womb is kept 'warm' - what this means in physiological terms is that the levels of hormones are kept high enough to encourage implantation and development of a new embryo. To this end yang tonic herbs are used in higher doses.

Acupuncture treatments followed the same theory although treatment was applied largely via the chong and ren and the 12 primary channels. It is the chong channel which empties of blood during the period and which must be replenished before ovulation can occur. Acupuncture is especially effective around the middle of the month when the mind needs to stay calm and the Fallopian tubes flexible and patent.

Herbal and acupuncture regimes
Formula A - herbs taken after the period from Day 4; tonify blood and yin, clear heat.

Shu di (Radix Rehmanniae Preparata) 10
Sheng di (Radix Rehmanniae) 10
Bai shao (Radix Paeoniae Lactiflora) 10
Dang gui (Radix Angelicae Sinensis) 10
Dan shen (Radix Salviae Miltiorrhizae) 10
Shan yu rou (Fructus Corni Officinalis) 10
Shan yao (Radix Dioscoreae Oppositae) 10
Gou qi zi (Fructus Lycii) 12
Nu zhen zi (Fructus Ligustri) 10
Han lian cao (Herba Ecliptae) 10
Huang bai (Cortex Phellodendris) 12
Zhi zi (Fructus Gardeniae) 5
Xiang fu (Rhizoma Cyperi) 10

The bulk of the herbs used at this time of the cycle are for building blood and yin. In Mary's case it was also important to keep internal heat under control or the yin would not build to a sufficient level for ovulation to occur. This formula is based on Zhi Bai Ba Wei Tang with the addition of several blood tonics and a couple of herbs to regulate qi and blood. The endometrium is being primed in this part of the cycle and growing in thickness - the blood tonics and regulators encourage this process. The yin tonics have their action on the growing follicle on the ovary.

Acupuncture points used after the period and before ovulation include Ren 4 guan yuan, Ren 7 yin jiao, Ren 3 zhong ji, Ki 14 si man to coordinate chong and ren channel function Ki 3 tai xi, Ki 6 zhao hai to tonify kidney yin, Liv 3 tai chong, Liv 8 qu quan, LI 4 he gu to calm liver fire, Ht 8 shao fu, Ht 7 shen men to calm heart fire.

Formula B - as soon as there was any fertile mucus then the following herbs were added to those of Formula A in an attempt to bring the egg to full size and provoke ovulation. Since the event of ovulation marks the switch from the yin part of the menstrual cycle to the yang part, yang tonics are added to promote this change in emphasis. In Mary's case keeping the heart and liver fire under control was important and herbs were added to address this.

Tu si zi (Semen Cuscutae) 12
Xian mao (Rhizoma Curculigonis) 6
Gou teng (Radix et Uncus Uncariae) 15
He huan pi (Cortex Albizziae) 10
Dan pi (Cortex Radicis Paeoniae Suffructicosae) 10
and huang bai and zhi zi were removed.

Acupuncture was employed to move qi and blood and calm the shen. Ht 8 shao fu, P 7 da ling, yin tang to calm the mind, Liv 3 tai chong to regulate liver qi, Sp 6 san yin jiao, Ren 4 guan yuan, Ki 3 tai xi to tonify kidneys, St 28 shui dao to regulate qi in the Fallopian tubes.

Formula C - once the temperature of the BBT chart had risen and stayed up for a couple of days a new formula was used

Du zhong (Cortex Eucommiae) 10
Xu duan (Radix Dipsaci) 10
Tu si zi (Semen Cuscutae) 10
Nu zhen zi (Fructus Ligustri) 10
Han lian cao (Herba Ecliptae) 10
Gou qi zi (Fructus Lycii) 12
Ji xue teng (Radix et Caulix Millettiae Dielsianae) 10
Dan shen (Racdix Salviae Miltiorrhizae) 6
Zhi xiang fu (Rhizoma Cyperi) 10
Sang ji sheng (Ramulus Loranthi) 15
Gou teng (Ramulus et Uncus Uncariae) 15
He huan pi (Cortex Albizziae) 10

The emphasis is on yang tonic herbs now but in Mary's case it was important to also maintain kidney yin with kidney yin tonics. Herbs to gently regulate qi and blood are also used in small doses. Blood regulating herbs are generally contraindicated in early pregnancy. However, in the time up until the first period is missed and shortly after, blood moving herbs can facilitate implantation of the embryo in the endometrium of the uterus. Sang ji sheng is added as a foetus calming herb. Finally, because yang tonic herbs can add heat to the liver, herbs to control liver fire are also added.

Acupuncture points; Liv 3 tai chong, Liv 8 qu quan to regulate liver fire, P 7 da ling, Ht 7 shen men, yin tang to regulate heart fire, Ki 9 zhu bin to tonify kidney yin and yang.

During her period Mary usually took a break from having herbs. Her period caused her little trouble and, since there seemed to be little evidence of stagnation, then it was not deemed necessary to continue treatment throughout the period. During the course of treatment as she was taking herbs to strengthen yin and blood, her period flow became more substantial.

CYCLE 5
Mary took Clomid from days 3 - 7 of her next cycle. She also took herbs and had acupuncture based on the approaches outlined above. Already in the first cycle we saw good progress. Her BBT chart (Chart 5) indicated that she ovulated on day 17 or 18, although she did not see any fertile mucus. As mentioned earlier, Clomid has an antioestrogen action and thus often inhibits production of fertile mucus. Because of this we used more herbs to build the yin preovulation in subsequent cycles. Mary noticed sore breasts from day 25. The luteal phase was 10 days - not quite long enough to be considered ideal but certainly a good start. A progesterone reading taken on day 24 was rather low, which indicated a less than adequate luteal phase. This means that even if there had been a conception the pregnancy would probably not develop because of lack of hormone support. Mary was still feeling hot and dry.

Her period came on day 28 and was a much improved flow due to the blood and yin tonics employed.

CYCLE 6
Because her first cycle had been a success the same Clomid regime was repeated.She took herbs similar to those in the first cycle and we planned to put more emphasis on tonifying yin in the lead up to ovulation to create more fertile mucus. However, this cycle did not get that far. Mary developed severe headaches, was thirsty, irritable and feverish. There was no fertile mucus and the very erratic BBT chart (Chart 6) indicated no ovulation. Her period came on day 20, and another cycle was embarked upon.

CYCLE 7
Clomid was taken on days 3 - 7 and the herbs were taken from day 4 with increased doses of shu di (Radix Rehmanniae Preparata) and other yin tonics and increased heat clearing herbs. This approach was successful because she saw fertile mucus on days 18, 19 and 20 and her BBT (see Chart 7) rose on day 21. This indicates an ovulation on day 20, which is a bit late to be ideal (fewer pregnancies result from late ovulations than those which occur at about the two week mark) but an ovulation nonetheless! After a couple of days of stable high temperatures we changed the formula to one based on Formula C and the luteal phase was a convincing 16 days, although the temperatures tended to drift downwards at the end. It is possible that Mary conceived in this cycle but that the embryo did not implant successfully.

It seemed to me that Mary's progress was very good, having just produced her most convincing ovulation in some time. However, the gynaecologist decided to increase the treatment at this point by adding hMG injections to the drug regime. hMG stands for Human Menopausal Gonadotrophin, so called because it is collected from the urine of menopausal nuns. It provides an external source of FSH which can directly stimulate the ovaries to ripen eggs and is often employed if clomiphene produces no response.

Recently, purer sources of FSH are becoming available with new techniques to synthesise the drug in the laboratory. The major risk of hMG is ovarian hyperstimulation syndrome and it is estimated that this occurs in some form in about 50% of the cycles in which it is used. In its mild form it is characterised by ovarian enlargement, perhaps with abdomen discomfort and in its most severe form it is a potentially life threatening condition, characterised by fluid accumulation in the abdomen, electrolyte disturbances and concentration of the blood. Mary did develop ovarian enlargement but, sadly, this was not accompanied by an ovulation. Since induction of ovulation is successful in more than 90% of hMG stimulated cycles this was surprising and disappointing.

CYCLE 8
Clomid 50mg was taken on days 3-7 and Metrodin (hMG) injections began on day 5, with regular monitoring for oestrogen and LH levels. It was anticipated that the oestrogen levels would rise from their base level as a follicle developed. However, by day 17 of this cycle, after the administration of 14 ampoules of Metrodin, the oestrogen was lower than it had been at the beginning of the cycle, indicating that there had been no response to either the Clomid or the Metrodin. Mary's abdomen was swollen and sore, the headaches returned as did the vaginal dryness.

She felt hot, teary and irritable. Mary took herbs based on Formula A for some of this cycle. The BBT chart (Chart 8) showed no pattern at all, indicative of an anovulatory cycle. The period came on day 42. The gynaecologist now told Mary she had 'Resistant Ovary Syndrome'. In this syndrome follicles are not responsive to FSH stimulation. However, he asked her to continue the clomiphene and have regular blood tests - maybe to hedge his bets.

CYCLE 9
Mary's fifth try with the Clomid got her nowhere. The ovaries had gone on strike again and her period came on the 19th day - an anovulatory cycle (Chart 9).

CYCLE 10
The same thing happened with the sixth try, an anovulatory cycle with her period coming on day 17 (Chart 10).

After 6 cycles using Clomid Mary had ovulated only twice. It was clear that the drugs were now having little effect and it was easy to persuade Mary and her husband to stop them for a while. The gynaecologist was still keen for her to try the Metrodin (hMG) again, and she kept having blood tests to monitor her cycle.

CYCLE 11
Mary took no drugs but took herbs every day. She was still feeling hot but was not flushing. She had no severe headaches. The vaginal dryness was gradually getting less until on day 15 the discharge became thicker and stretchy. We were able to change the herbs to ones to promote ovulation (based on Formula B) at this point. The BBT rose by day 19 (see Chart 11) and Mary switched to herbs based on Formula C a couple of days later. The temperature stayed elevated for 12 days and her period came on day 31.

CYCLE 12
We now saw a steady improvement. Mary followed the same herb regime as previously. She saw fertile mucus on day 14 and the temperature rose immediately (Chart 12). Her period came on day 28 making this almost a textbook cycle and given Mary's recent track record and her medical diagnosis it was cause for much optimism. She still sometimes felt a little hot and thirsty but this was not marked. Once again, just when things were looking good, the gyanecologist planned another hMG treatment at this point. However, now that Mary could see the improvements she was gaining with the herbs on their own, and after two good cycles, she and I were keen to persist with the regime she was on and leave the hMG alone.

CYCLE 13
Everything continued to go pretty much like clockwork - she stuck with the same herb regime and her BBT (Chart 13) indicated an ovulation on day 16. By day 30 the temperature had been elevated for 14 days - this was the best yet luteal phase we had seen and Mary could not wait to do a pregnancy test. An amazing positive!

Mary's pregnancy was, of course, not uneventful and her back caused her a lot of trouble. Nevertheless, she gave birth to a large and healthy baby boy at term.

What Chinese medicine did for Mary was to provide another avenue when western medicine put her in the cannot-do basket. Chinese herbs will not avert every premature menopause but where there is a modicum of kidney yin left to salvage it is a skilful, tried and tested method to apply, with little risk of side effects. Almost immediately after she began the herbs to purge internal fire and the herbs to astringe the yin Mary started to produce cervical secretions which were thick and stretchy. To a TCM fertility specialist this is an important sign that there was indeed still kidney yin (in this case in the ovaries) that we could work with. So there was good reason to pursue the goal with fervour from that point (and believe me it takes fervour to consume literally hundreds of packets of Chinese herbs, let alone religiously take your waking temperature every day and be prodded with needles and fingers on a regular basis.) This case also illustrates the sorts of mixing of modalities and methods that so often occurs in clinics in the West, and especially in fertility clinics. When time is short and desperation is high then the TCM practitioner must learn to work with whatever therapies are on offer - sometimes the combination of Chinese and western medicine is a happy marriage with fortunate outcome and other times the two need to work separately. In Mary's case, as it turned out, her body responded better to Chinese herbs but maybe for her second child she will need to use a donor egg and IVF procedures.