PART I [3 pages total]: WESTERN MEDICINE (10%)

“According to World Health Organization (WHO) [or whomever you cite], infertility is

defined as “… [for example]

“Systemic reviews on the acupuncture and herbal medicine (AOM) treatments for

managing gynecologic conditions [for example] … [Include Literature Review of Condition in

General and Specific to your patient, pubmed etc.]

AOM (10%)

Infertility has been recognized as a treatable disease with complementary and alternative

medicine [how is your patient’s condition related to infertility typically treated in WM and AOM?

What are options and outcomes? Evidence and Approaches?]

PART II: A Case Report of Infertility (40%) 3-5 Pages

A 31-year-old nulliparous Caucasian female graduate student presented with a chief complaint of

painful and heavy menstrual bleeding secondary to a uterine myoma impairing fertility. She was

diagnosed 18 months previously via ultrasound by her Gynecologist, but her symptoms began, and

have been increasing in severity, over the last four months. She has an otherwise normal menstrual

history with menarche at age 11 and a regular 28-day interval. She reports that this interval has

been decreasing over the last several months and breakthrough spotting has begun to occur at mid-

cycle. At present, Cycle Day (CD) 1 presents with light red bleeding and increasing lateral and

central sharp pelvic pain that radiates to her sacrum. By CD2, the pain and bleeding are most

intense with large dark clots and periodic gushing of watery blood that can require her to change

her sanitary protection every two hours through CD 4, after which the bleeding subsides

completely. She rates the pain as a 5 on a 0-6 scale that can wake her from sleep. 400 mg ibuprofen

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every four hours, movement, massage and heat application can provide temporary pain relief. She

additionally reports dyspareunia, fatigue, intolerance to cold, frequent thirst, and a tendency to

constipation. She denies other systemic complaints upon review of systems. Recently married and

soon to complete her PhD, she is hoping to start trying to conceive within the year.

Objective measures include an overall weak and thin pulse, notably empty at the left cun mai. Her

tongue is pale, slightly dry with thin white fur and clear sublingual veins. Her abdomen is soft,

complexion sallow, and demeanor calm.

Western Diagnosis:

Myoma induced Menorrhagia and Dysmenorrhea with Primary Infertility

TCM Diagnosis:

This patient was diagnosed with Vacuity of Yang Qi in the Spleen and Kidney causing Blood

Vacuity and Stasis with secondary localized exterior heat in the lower burner.

Treatment Principles:

The treatment principles were to Fortify the Spleen and Boost the Kidney to Support the Yang-Qi,

which in turn will nourish and move Blood. Secondary principle was to clear exterior heat in the

lower burner.

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Treatments and progress:

Acupuncture was initiated on CD 6 after the bleeding was complete using the following points:

Du 20 (Bai hui), Ear Shen Men, Lung 9 (Tai yuan), St 36 (Zu san li), Ren 4 (Guan yuan), Ren 6

(Qi hai), Sp 6 (San yin jiao), Sp 1 (Yin bai) with moxibustion, and K 3 (Tai xi).

Chinese herbal formula :

She was prescribed an herbal formula based on Gu Ben Zhi Beng Tang (Stabilize the Root and

Stop Excessive Uterine Bleeding Decoction) to take for the next two weeks to consolidate Qi and

a stronger modification to take at the onset of her next period to more aggressively control bleeding

and pain.

Recommendations:

[Diet, exercise, etc go here]

Discussion:

Uterine myomas are a frequent cause of menorrhagia and dysmenorrhea in reproductive age

women and can lead to anemia and other complications. There is often a genetic component and

symptoms can vary over time (Mayo Clinic). Surgical intervention is often required if there is a

bladder or bowel obstruction or if the patient desires pregnancy. Without these complications,

symptoms can effectively be treated with acupuncture and herbs that at a minimum can reduce the

bleeding and pain, but may also be able to reduce the size of the myoma (Liang, p 209), but

conclusive studies are lacking (Smith, Liu). Leiomyomas, also called fibroids, are a type of non-

cancerous tissue overgrowth in Western Medicine and classified as a type of zheng-jia, or mass,

in Chinese Medicine. The underlying cause must be determined to effectively treat the mass and

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its symptoms: in this case, the bleeding and pain. Pain signifies stagnation in Chinese Medicine

and bleeding has three common etiologies: Spleen/Kidney Yang-Qi Vacuity not holding blood in

the vessels, Heat of any type inducing reckless marauding of hot blood causing extravasation from

the vessels, or Blood stasis from any cause, including cold, trauma, or vacuity, where new blood

re-routes out of the vessels to move. (Ellis & Wiseman, p. 150-1) This patient’s presentation

suggests the first cause of bleeding and pain, Sp/K vacuity of Yang-Qi not holding blood in the

vessels as her supporting signs and symptoms were those of deficiency: fatigue, weak pulse, pale

face and tongue, mid cycle spotting and gushing watery bleeding during the menses, a type of

Beng-Lou, or Flooding and Spotting disorder. Pain signifies stasis and the lower back suggests

Kidney involvement. As a result of prolonged blood loss, she also exhibits some blood vacuity

and dryness symptoms including thirst and constipation, as well as emptiness in her Heart pulse

position. As the Heart governs the Blood, vacuity will manifest frequently here along with the

pallor she exhibits in her face and tongue, also outward reflections of the Heart Blood. The Five

Element relationship between the Spleen Earth, prone to excessive deliberation in a graduate

student, and the Heart Fire, is one of vacuity in the Child (Earth) draining that of the Mother (Fire).

The relationship of these two organs is through the Blood and thus manifests there. (Bensky, p.

256). Nourishing this vacuity will resolve stasis and thus pain. Her secondary complaint presented

with only a localized heat pattern of labial burning but no other heat signs or symptoms presenting

systemically, thus it was determined that this would be treated topically and separately from the

other primary complaints.

The acupuncture points were selected to Tonify and Boost the Yang-Qi in her Spleen to generate

and regulate production of Qi and Blood, stop bleeding, and regulate movement to prevent

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stagnation and therefore reduce pain (Du 20, Ren 4 and 6, St 36, and Sp 6) and moxa was used on

Spleen 1, which is empirical to stop bleeding due to weakness in the Spleen’s ability to contain the

blood. Kid 3 (Tai xi) was selected to support the prenatal source of Qi, and L9 to support the Tai

Yin partner of the Spleen to help generate Qi which will then engender Blood. (Chen)

The herbal formula, a modified Gu Ben Zhi Beng Tang (Stabilize the Root and Stop Excessive

Uterine Bleeding Decoction), a modification of the more popular Gui Pi Wan (Restore the Spleen

Pill) was composed of the following herbs which will support the Sp and K Yang Qi and Blood

and mildly control bleeding to prevent midcycle breakthrough: Huang Qi (Astraglus Rx), Chao

Bai Zhu (Fried White Atractylodes Rz), Fu Ling (Poria), Lian Zi (Nelumbinis Sm), Ren Shen

(Ginseng Rx), Xu Duan (Dipsacus Rx), Gou Ji (Cibotii Rz), Du Zhong (Eucommia Cx), Dang Gui

(Angelica Sinensis Rx), Shu Di Huang (Rehmannia Rx), Pao Jiang (Blast Fried Zingeberis Rz),

and Duan Mu Li (Calcined Concha Ostrea). This formula was then strengthened to take the week

of her bleeding to help control the heavy loss and pain by adding Duan Long Gu (Calcined Ossa

Fossilia), E Jiao (Corii Asini Gelatinum), Bai Shao (Peony Alba Rx), Shan Zhu Yu (Corni Fr), Pu

Huang Tan (Charred Pollen Typhae), Ai Ye Tan (Charred Artemesia Argyi Folium) and removing

the Ren Shen, Du Zhong, Dang Gui, and Shu Di Huang to prevent stagnation from forming while

controlling loss. Secondarily, she used vaginal suppository of cocoa butter based l-acidophilus

and tea tree oil to be used nightly until the period begins. .

[Please detail each acupuncture point and herb with dosing and specific applications to your patient

based on functions of the points, herbs and formula]

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Results

The patient reported improved and sustained energy and mood following her acupuncture

treatment and had no side effects upon commencing the herbal formula. She was treated weekly

with acupuncture and took the herbs 3 x day, and upon the onset of her next menstrual bleed, she

reported a noticeable reduction in both pain (reduced to almost none) and bleeding to tolerable

levels that did not require as frequent medication or changing of sanitary protection.

Response would typically be within three menstrual cycles of commencing treatment with

acupuncture and herbs for most menstrual complaints, however this patient’s clear presentation

and compliance to treatment brought a much quicker significant relief of symptoms. Vacuity

causes of bleeding often respond slower than heat and stasis causes, but this case was a notable

exception. (Liang, p. 88) Her complaint resolved after a few successive treatments and she was

able to successfully conceive and carry to term a healthy baby boy.