许淑怡’，叶骞’，叶平2壤 2009年4月第29卷第4期 JiLin Journey of Traditional Chinese Medicine 2009．v01．29．No．4
Translated by XU Zhi-jun & J. Heaverlo
中医对不孕症的认识源远流长，在中医古籍中，不孕症的病名有不孕、无子、绝产、断 绪、全不产等称谓。概括其对病因病机的认识有肾虚、瘀血、痰湿、经络为病、月经不 调、外感内伤等。辨证论治包括从肾论治、从气血论治、从瘀论治、从痰论治、从郁论 治，还有针灸疗法、外治法。在预防调护方面，有“男养精，女养血”“合男女必当其年” 的记载，并提倡调情志、节嗜欲。
The Ancient Chinese Doctors Understanding and Treatment of Infertility
Chinese medicine has a long history of understanding and treating infertility. In the ancient books of Chinese medicine, infertility syndrome is also referred to as “infertility”, “without offspring”, “breaking lineage”, and “complete infertility”. The causes of infertility and it’s pathomechanisms are summarized as: kidney vacuity, static blood, phlegm-damp, disease of the channel and network vessels, menstrual irregularities, and external contraction with internal damage. Pattern identification for determining treatment includes treating the kidneys, qi and blood, stasis, phlegm, and depression. Besides acupuncture and moxibustion, additional external treatments may also be applied. In regards to prevention and regulation, it is written that “a man should nourish his essence and a woman should nourish her blood”, as well as, “both men and women should begin sexual activity at an appropriate age.” It is also advocated to regulate one’s affect-mind and control one’s sensual desires. Key Words: infertility; pathomechanism; kidney vacuity; static blood; phlegm-damp; external contraction ________________________________________________________________________________________________ 不孕症是妇科的常见病，近年来全世界的不孕人数有增加的趋势。进入2l世纪的人类，更加关注自身的生殖健康和生育的权利，使不孕症的研究亟待深入。中医对不孕的认识源远流长，早在公元前11世纪《易经·爻辞》中即有“妇孕不育” “妇三岁不孕”等关于不孕不育的最早记载。现就古代医家对不孕的认识论述如下。
In gynecological medicine, infertility is a commonly seen disease. In recent years, the number of infertility cases globally has continued to increase. As we enter into the 21st century, men and women are increasingly paying more attention to their reproductive health, as well as, their right to pro-create. Therefore, infertility research has begun to search for a deeper understanding of this syndrome. Chinese medicine has a long history of understanding and treating infertility. The earliest writings about infertility and sterility can be found in the Yì Jīng·Yáo Cí 《易经·爻辞》(“Book of Changes-Trigrams”) from the 11th century B.C, where it describes: “the woman who carries a child but does not bring it forth” and “for three years the woman cannot carry a child”. This paper is intended to explore how ancient Chinese doctors understood and treated infertility.
《周易》最早提出不孕病名及不孕年限的界定。在中医古籍中，不孕的病名有不 孕、无子、绝产、断绪、全不产等称谓。如《素问·骨空论》云：“督脉者⋯⋯此为病⋯⋯其女子不孕”⋯。《素问·上古天真论》云：“七七，任脉虚，太冲脉衰少，天癸 竭，地道不通，故形坏而无子”。《脉经》云：“妇人少腹冷，恶寒久，年少者得 之，此为无子，年大者得之，绝产。”《诸病源候论》专列“无子”一条，对本病之病因加以探讨。《千金方》记载“妇人立身已来全不产，及断绪久不产三十年者”，将不孕分为全不产和断绪，前者即“原发性不孕”，后者相当于“继发性不孕”。
1. The evolvement of the disease name
The Yì Jīng《易经》(“Book of Changes”) was the first text to employ the name “infertility” and the first to define the age limit of infertility. In the ancient books of Chinese medicine, infertility is also referred to as “childless”, “without offspring”, “breaking lineage”, and “complete infertility”. For example, the Sù Wèn-Gú Kōng Lùn《素问·骨空论》(“Plain Questions· Treatise on Bone Hollow”) states, “When there is disease in the Governing Vessel…the woman cannot carry a child”. The Sù Wèn·Shàng Gǔ Tiān Zhēn Lùn 《素问·上古天真论》(“Plain Questions－Treatise of Heavenly Truth from Remote Antiquity”）, states, “At the age of 49, the controlling vessel becomes vacuous, the great thoroughfare vessel starts to debilitate, the menstruation becomes exhausted, and the pathway becomes obstructed. Therefore, the body declines and cannot bear children”. The Mài Jīng《脉经》(“The Pulse Canon”) states, “If a woman has cold in the abdomen, feels aversion to cold for a long time, and is still in her youth, this will result in infertility. If she is older it will result in complete infertility.” In Zhū Bìng Yuán Hòu Lùn《诸病源候论》(“The Origin and Indicators of Disease”), the author recorded “infertility” as an entry and further explored the causes of this disease. The Qiān Jīn Fāng《千金方》(“Thousand Gold Pieces Formulary”) describes “a woman who physically is incapable of pregnancy”, and “a woman whom for more than thirty years has been unable to conceive”. Here it is divided into “complete infertility” and “breaking lineage”. The former is “primary infertility” and the latter is “secondary infertility”.
自《素问·上古天真论》提出“女子七岁，肾气盛，齿更发长，二七而天癸至，任脉 通，太冲脉盛，月事以时下，故有子”以来，肾为生殖之本的论点就为历代医家所认同。《圣济总录》云：“妇人所以无子者，冲任不足，肾气虚寒故也”，说明胞宫失于温煦，宫寒不能摄精成孕而成本病。傅青主也认为不孕之本在肾口，种子门载有不孕病因十条：“身瘦不孕、胸闷不思食不孕、下身冰冷不孕、胸满少食不孕、少腹急迫不孕、嫉妒不孕、肥胖不孕、骨蒸夜热不孕、腰酸腹胀不孕、便涩腹胀足浮肿不孕”，其中有6条论及肾，如“妇人有下身冰冷，非火不暖⋯⋯胞宫既寒，何能受孕⋯⋯胞胎之寒凉，乃心肾二火之衰微也。”指出肾火不足、胞宫寒冷致不孕。又有云：“况瘦人多火⋯⋯此阴虚火旺，不能受孕。”指出肾阴虚所致不孕；及肾气不足、膀胱气化不利致“便涩腹胀浮肿不 孕”等。
2. The Disease Causes and Pathomechanisms
2.1 Kidney Vacuity
As the Sù Wèn 《素问·上古天真论》(“Plain Questions· Treatise of Heavenly Truth from Remote Antiquity”) points out, “When a female reaches the age of seven, her kidney qì becomes exuberant, her teeth change and her hair grows. At the age of 14, her reproductive ability arrives, the controlling vessel opens, the great thoroughfare vessel becomes exuberant, the menstruation comes regularly, and she is able to bear children.” Since the time of the Sù Wèn《素问》(“Plain Questions”), the theory that the kidneys act as the root of reproduction has been widely accepted by the ancient physicians. The Shèng Jì Zǒng Lù《圣济总录》 (“Sages’ Salvation Records”), states, “A woman is childless because her thoroughfare and controlling vessels are insufficient and her kidney qì is vacuous and cold”. This seeks to explain that infertility is due to the uterus’s lack of warmth, and therefore, uterine cold leads to infertility. Fù Qīngzhǔ (傅青主) also agreed the root cause of infertility lies within the kidneys. Zhǒng Zǐmén (种子门) listed ten causes for infertility: “A woman can’t become pregnant if her body is thin; if she feels oppressed in the chest and does not want to eat; if her lower body is icy-cold; if she feels full in the chest and eats too little; if her lesser abdomen is distressed; if she is envious; if she is obese; if she has steaming bone syndrome and night fevers; if she has an aching lumbar and abdominal distention; or if she has difficult urination, abdominal distention and floating edema of the feet”. Among these, six causes have a relationship with kidneys. For example, “If the woman’s lower body is icy-cold and can’t become warm without fire…how can she become pregnant with uterine cold… uterine cold results from the debilitation of heart and kidney fire”. This clearly states that kidney fire insufficiency and uterine cold lead to infertility. It further reads “thin people have more fire. This is yīn vacuity with fire effulgence, which creates the inability to conceive.” This further points out kidney yīn vacuity leads to infertility; and insufficient kidney qì and inhibited bladder qì transformation leads to “infertility because of difficult urination, abdominal distention and floating edema”.
《针灸甲乙经》提出瘀血是不孕之因，“女子绝子，坏血在内不下”。《医宗金鉴》云：“不子之故伤冲任⋯⋯或因积血胞寒热。”说明气血失和导致瘀血内阻，胞脉受 阻，冲任不通不能成孕口。《傅青主女科》云：“疝瘕碍胞胎而外障，则胞胎必缩于疝瘕之内，往往精施而不能受。”《石室秘录》云：“任督之间倘有瘕瘕之症，则精不能施，因外有所障也”，明确指出瘀血等有形之物可以阻碍精子通过胞络而影 响受孕。《张氏医通·妇人门》云：“因瘀积胞门，子宫不净，或经闭不通，成崩中不止，寒热体虚而不孕者。”又云：“妇人立身以来全不产。⋯⋯此胞门不净，中有瘀积结滞也。”亦持瘕瘕积聚可致不孕之观点。王清任善用活血化瘀之法，其从瘀论治不孕获奇效，从而论证瘀血确为不孕致病之因。
2.2 Blood stasis
Zhēn Jiū Jiǎ Yǐ Jīng 《针灸甲乙经》 (“The Systematized Canon of Acupuncture and Moxibustion”) proposes that blood stasis is the cause of infertility. “Female infertility results from the internal retention of spoiled blood”. Yī Zōng Jīn Jiàn《医宗金鉴》(“The Golden Mirror of Medicine”) states, “Infertility is because the thoroughfare and controlling vessels are injured… or because the uterus is both cold and hot due to accumulated blood.” This explains that infertility results from a disharmony of qì and blood, which leads to internal static blood obstruction of the uterine vessels, and of the thoroughfare and controlling vessels. Fù Qīng Zhǔ Nǚ Kē《傅青主女科》(“Fù Qīngzhǔ: Gynecology”) states, “Mounting-conglomeration impedes the uterus, which leads to external obstruction, and thus the uterus must retract into the mounting-conglomeration. More often than not, even though the semen is without defect, the uterus cannot be fertilized.” The Shí Shì Mì Lù 《石室秘 录》(“Secret Record in the Stone Chamber”) states, “If conglomerations exist between the controlling vessel and the governing vessel, the semen will be inhibited due to the external obstruction.” It is explained clearly that the tangible matter, such as blood stasis, is likely to impede the semen from passing through the uterine network vessels and thus affect the fertility. Zhāng Shì Yī Tōng·Fù Rén Mén 《张氏医通·妇人门》 (“Zhang’s Clear View of Medicine·On Women”), also supports the viewpoint that conglomerations can lead to infertility. “Some women can’t become pregnant because stasis accumulates at the uterine gate, the uterus is not clear, or because the menstruation is blocked and incessant flooding happens, furthermore, the constitution is weak due to cold and heat.” It again states, “A woman cannot be pregnant at all …because the uterine gate is not clear, and there is blood stasis accumulation within.” Wáng Qīngrèn (王清任) used the method of blood-quickening, stasis-transforming to treat infertility from blood stasis. Using this method he was able to obtain miraculous results. This exemplifies that blood stasis is indeed one of the main causes of infertility.
Zhū Dānxī (朱丹溪) was the first to point out that phlegm-damp is likely to cause infertility. In the Dān Xī Xīn Fǎ《丹溪心法》(“Dān Xī’s Heart-Methods”) Zhū Dānxī (朱丹溪) points out, “Women who are overweight and thick, and those who indulge in wine and food, suffer from menstrual irregularities and cannot establish a pregnancy. This is because too much body fat will overflow and block the uterus.” According to Zhū Dānxī (朱丹溪) , “The fat layer of overweight women can congest the uterus”, as well as，“latent heat lies in their thoroughfare and controlling vessels”, both of which are causes of infertility. The Jì Yīn Gāng Mù《济阴纲目》(“Compendium of Helping Yīn ”) put forward the patterns and treatments of “phlegm-rheum leading to infertility” and “replete phlegm in the chest”. The Fù Qīngzhǔ Nǚ Kē《傅青主女科》(“Fù Qīng Zhǔ: Gynecology”) also states, “If a woman cannot become pregnant, it is due to obesity and too much phlegm-drool, which originates from the internal disease of spleen-earth. Most of those with damp encumbrance are overweight, most of those who are overweight have qì -vacuity, and most of those who have qì vacuity have too much phlegm-drool. The spleen itself is damp, and too much phlegm will intensify this dampness. This will be too much for the spleen to bear and the fetus will be infiltrated. If occurring over a long period of time, the internal flesh will certainly become full; the uterus will be blocked and will not be able to become fertilized. This is an inevitable outcome.”
2.4 Diseases of the channels and network vessels
The Sù Wèn《素问》(“Plain Questions”) states, “A female with the disease of the governing vessel cannot become pregnant.” This points out the relationship between infertility and the channels and network vessels. The Gé Zhì Yú Lùn《格致余论》 (“Further Treatises on the Properties of Things”) states, “The sea of blood is too hot.” The Nǚ Kē Jīng Lún《 女科经纶》(“The Classics of Gynecology”) quoted Zhū Dānxī (朱丹溪), “A woman will suffer from chronic infertility due to latent heat in the thoroughfare and controlling vessel, while internal heat leads to the desiccation of the luxuriant blood.” The thoroughfare and controlling vessels are the most important among the channels and network vessels. “The thoroughfare vessel is the sea of blood”, and “the thoroughfare vessel is the sea of the twelve channels, which can regulate the qì and blood of the twelve channels.” “The controlling vessel governs the uterus”. Damage to the thoroughfare and controlling vessels will inevitably result in gynecological diseases.
2.5 Menstrual irregularities
Infertility is closely related to menstrual irregularities. Zhū Dānxī (朱丹溪) once said, “In many cases, females cannot become pregnant because they suffer from blood scantiness and thus cannot receive essence, the menstrual flow becomes irregular and the woman is unable to conceive”. The Jì Yīn Gāng Mù 《济阴纲目》 (“Compendium of Helping Yīn”) gives a relatively specific exposition on the symptoms of infertility and menstrual irregularities, “Each time we see a female who is unable to conceive, it will be likely her menstruation is too early or too late, too heavy or too light, or there is pain before or after menstruation. The menstrual blood will be purple, black or pale, or congealed with clotting and irregular. Irregularity leads to the disharmony of blood and qì therefore leading to infertility.” The Jǐng Yuè Quán Shū·Fǔ Rěn Guī《景岳全书 ·妇人规》(“Jǐng Yuè’s Complete Compendium· Discourses on Women”), emphasizes the relationship of menstruation and pregnancy. It sates, “What is important to women is blood. Blood has the ability to create essence, henceforth pregnancy,” and “gynecological diseases are derived, firstly from menstrual blood”, “when there is regular menstruation, this will produce offspring.” According to Wáng Hónghàn (王宏翰), physician of the Qīng Dynasty, “When yīn loses its path, conception cannot occur. This is because qì is exuberant and the blood is depleted. Once debilitated, cold and heat break through, the qì will congeal and the blood will become stagnant, leading to the construction and defensive to become disharmonious. This leads to irregular menstrual flow.” This quotation illustrates how infertility results from “exuberant qì and debilitated blood”. Women are of yīn and are governed mainly by blood. Therefore, blood vacuity may lead to infertility.
2.6 External contraction and internal damage
Infertility is also related to external contraction of the six excesses, internal damage by the seven affects, and sexual taxation. During the Míng Dynasty, Xuē Jǐ(薛己) in his text Xuē Shì Yī Àn《薛氏医案》(“Xuè’s Case Histories”) points out, “In some cases, women’s infertility results from the evil of the six excesses and the seven affects, which injure the thoroughfare and controlling vessels. The Jì Yīn Gāng Mù《济阴纲目》(“Compendium of Helping Yīn”) states, “The concubines have excessive depression, their affect-minds are blocked, they have excessive menstruation which cannot be regulated, hence it is difficult to become pregnant”. Jǐng Yuè Quán Shū《景岳全书》(” Jǐng Yuè’s Complete Compendium”) expounds the mechanism that the affect-mind can cause disease, “Childbirth depends on qì and blood, qì and blood depend on the affect-mind. If the affect-mind is not smooth this leads to insufficiency of the thoroughfare and controlling vessels, which leads to infertility.” During the Qīng Dynasty, Chén Xiū Yuán (陈修园), in Nǚ Kē Yào Zhǐ《女科要旨》(“The Main Points of Gynecology”) he states, “All infertility results from the internal damage of the seven affects and the external contraction of the six excesses, or from abnormal exuberance of qì and blood, and overwhelming of yīn and yáng.” In Féng Shì Jǐn Náng Mì Lù ·Nǚ Kē Jīng Yào《冯氏锦囊秘录·女科精要》(“Féng’s Embroidered Bag of Secret Records- Essentials of Gynecology”) expounds, “In some cases, infertility results from the damage of the thoroughfare and controlling vessels by the six excesses and the seven affects, the uterus is cold and vacuous, or there is latent heat in the blood, or accumulated blood and phlegm stagnating the uterine network vessels”. This points out that the affect-mind can bring about disease. Blockage of the uterine network vessels is one of the main causes of infertility. Furthermore, an intemperate lifestyle is also likely to cause infertility. Jì Yīn Gāng Mù《济阴纲目》(“Compendium of Helping Yīn”) points out, “Excessive sexual activity exhausts the blood and weakens the body, excessive breastfeeding withers the blood and can lead to death”.
3. Pattern Identification As The Basis For Determining Treatment
3.1 Determining treatment according to kidney patterns
The Kidneys govern reproduction. Some doctors put forward the viewpoint of treating infertility according to the kidneys. For example, the Qiān Jīn Yì Fāng《千 金翼方》(“Wings of the Thousand Gold Pieces Formulary”) states, “Those who want children have no reason to fail if taking together Zǐ Shí Mén Dōng Wán (紫石门冬丸).” While the Tài Píng Shèng Huì Fāng 《太平圣惠方》(“The Great Peace Sagacious Benevolence Formulary”) states, “Yáng Qǐ Shí Wán (阳起石丸) should be adopted to treat women’s enduring accumulated vacuity cold in the sea of blood causing childlessness.” Both Zǐ Shí Mén Dōng Wán (紫石门冬丸) and Yáng Qǐ Shí Wán (阳起石丸) are formulas that warm the kidneys and uterus. This is a suitable treatment for those who suffer from infertility due to debilitation of kidney yáng and uterine cold. Fù Qīngzhǔ (傅青主) from the perspective of kidney yīn and yáng, water and fire, put forward the principles of treatment of supplementing the blood to engender the essence, boosting qì to engender the essence, warming and moistening to replenish the essence, center the qì to supplement yáng, secure and contain the kidney’s essence, as well as yīn and yáng. Fù Qīngzhǔ Nǚ Kē《傅 青主女科》(“Fù Qīng Zhǔ: Gynecology”) states, “Infertility must be treated by greatly supplementing the kidney water and calming the liver-wood. Effulgent wood makes effulgent blood. This is not only for supplementing blood but also for replenishing essence. Sufficient essence and blood make it easier for the uterus to become fertilized. All of these are ways to aid conception.” The text further explains, some women who suffer from infertility “have little thought of food and drink, a sensation of fullness, oppression of the chest, fatigued and drowsy all day long, and groan incessantly after having sexual intercourse. This has been ascribed to qì vacuity in the spleen and stomach, when in fact it is actually due to kidney qì insufficiency and must be treated by supplementing the kidney qì. However, if you do not simultaneously supplement the spleen and stomach, the qì of the water and fire within the kidneys cannot rise up to the top of zhì yáng (阳之) (GV 9-extremity of yáng).”
从气血论治，调经为先者，如朱丹溪云：“求子之道，莫如调经。”《万氏妇人科》亦云“女子无子，多因经候不调⋯⋯调经为女子种子紧要。”《景岳全书》立“育麟珠”用于补气血调经，极效。《宋氏妇科秘书》立“百子建中丸”治“妇人久冷，赤白 带下，肚腹疼痛，经水不调”，方以“温中暖脐、调经开郁、开胃”为法，“服至半 月，必有孕矣”。王肯堂论不孕亦强调气血平和，调经种子，谓“滞者香附、缩砂、 木香、槟榔、桃仁、延胡。滞久而沉痼者吐之下之。脉证热者四物加芩连⋯⋯值至积去滞行虚回，然后血气平和能孕子也。”《沈氏女科辑要》也说：“求子全赖气血充足，虚衰则无子”。《妇科玉尺》认为“求嗣之术，不越男养精、女养血两大关键”，而“养血之法，莫先调经”，可用香附末醋丸、琥珀调经丸等治疗。傅青主疗不孕，亦重调护气血”，认为“不损天然之气血”“妊娠一门总以补养气血为主”。
3.2 Determining treatment according to qì and blood
Some doctors place regulation of the menses as the primary objective when determining treatment according to qì and blood diagnosis. For examples, Zhū Dānxī (朱丹溪) says, “No other method is better than regulating menstruation in order to become fertile.” Wàn Shì Fù Rén Kē《万氏妇人科》(“Wàn’s Gynecology”) also states, “In most cases, a woman cannot conceive because of irregular menses. Regulating menstruation is the vital point for a woman to become pregnant.” Jǐng Yuè Quán Shū《景岳全书》(“Jǐng Yuè’s Complete Compendium”) uses ” Yù Lín Zhū ” (育麟珠) to supplement qì and blood in order to regulate the menses, thereby achieving optimal results. The Sòng Shì Fù Kē Mì Shū《宋氏妇科秘书》(“Sòng’s Secret Book of Gynecology”) treats “women’s enduring cold, red and white vaginal discharge, abdominal pain, and irregular menstrual flow” with Bǎi ZǐJiàn Zhōng Wán (百子建中丸) (“Bǎi ZǐStrengthen the Center Pill”). The text suggests using the method of warming the center and navel, regulating menstruation and opening depression, as well as regulating the stomach in order to increase the appetite”. The text further states, “After taking for this prescription for half a month, pregnancy must occur”. Wáng Kěntáng (王肯堂), on the topic of infertility, also places emphasis on calming and harmonizing qì and blood and regulating menstruation. He says, “If qì and blood are stagnant, use xiāng fǔ (相府), suō shā (縮砂), mù xiāng(木香), bīn láng (槟榔), táo rén (桃仁), and yán hú (延胡). If the stagnation is enduring and chronic, let it vomited and precipitated. If the pulses and symptoms indicate heat then use these four agents with qín lián (芩连), then qì and blood will be calm and harmonious allowing for conception.” Shěn Shì Nǚ Kē Jí Yào《沈氏女科辑要》(“The Summary of Shěn’s Gynecology”) also states, “Pregnancy all depends on sufficient qì and blood. Debilitation leads to infertility”. According to the Nǚ Kē Yù Chǐ《妇科玉尺》(“The Jade Ruler of Gynecology”), “The methods to become pregnant do not contain more than two points: the male nourishes his essence and the female nourishes her blood.” “The first thing to do in order to nourish blood is to regulate menstruation”, xiāng fú mò cù wán (香附末醋丸) (Cyperus Rotundus Vinegar Pills) and hǔ pò diào jīng wán (琥珀调经丸) (“Amber Regulate the Menses Pill”) can be used for treatment. Fù Qīngzhǔ (傅青主) also attaches great importance to regulating and protecting the qì and blood. He warns, “Do not injure qì and blood”, “The first objective for fertility is to supplement and nourish qì and blood”.
3.3 Determining treatment according to blood stasis
The Qiān Jīn Fang《千金方》(“Thousand Gold Pieces Formulary”) states, “No woman will fail to become pregnant if she takes zǐ shí mén dōng wán (紫石门冬丸) (Flourite and Ophiopogon Pill) along with the medicinal soak dàng bāo tāng，(荡胞汤) (Uterus Sweeping Decoction)”. The text continues to state, “those who have been infertile for 20 or 30 years…their uterus must have accumulated blood…which should be primarily treated with dàng bāo tāng (荡胞汤) (Uterus Sweeping Decoction)”, dàng bāo tāng (荡胞汤) (Uterus Sweeping Decoction) is for dispelling blood stasis and precipitating accumulation, which is taken as the first method for infertility according to the Qiān Jīn Fāng《千金方》(“Thousand Gold Pieces Formulary”). This formula is used for “treating those women who break lineage for 20 or 30 years, or who cannot become pregnant from birth, or who have miscarriages again and again”. Wáng Qīngrèn (王清任) was adept at treating many forms of diseases by using the method of quickening the blood and transforming stasis. He also gained extraordinary efficacy on treating infertility with this approach.
3.4 Determining treatment according to phlegm accumulation
Zhū Dānxī (朱丹溪) was the first to advocate “When the body is exuberant with fat, the uterus will be blocked. In this case, the method of moving dampness and drying phlegm should be adopted”. Féng Shì Jǐn Náng Mì Lù《冯氏锦囊秘录》(“ Féng’s Embroidered Bag of Secret Records”) lists qǐgōng wán (启官丸) (Uterus-Opening Pill) to treat “the infertile woman whose uterus is exuberant with fat and congestion”. It further points out that phlegm-damp infertility should be treated chiefly with qǐgōng wán (启官丸) (Uterus-Opening Pill), which is a simple but effective medicine. Fù Qīng Zhǔ Nǚ Kē《傅青主女科》(“Fù Qīngzhǔ: Gynecology”) states, “this must be treated with the method of discharging water and transforming phlegm”.
3.5 Determining treatment according to depression
If the affect-mind is unsmooth, this can also lead to infertility. The text Jì Shēng Fāng《济生方》(“Life-Saving Formulas”) put forward the method of coursing the liver and resolving depression, nourishing the blood and rectifying the spleen to treat infertility. It states, “That when a women’s blood is debilitated and her qì is exuberant. This is referred to as “Fū Bìng Fù Zhěn” (夫病妇疹) (see foot note). This will certainly lead to infertility. As to the method of treatment, the female should nourish her blood and repress her qì, so as to reduce excess joy and anger.” Fù Qīng Zhǔ Nǚ Kē《傅青主女科》(“Fù Qīngzhǔ: Gynecology”) states, “If the liver-wood is constrained, it will descend to invade the spleen-earth, leading to congestion”, thus “closing the uterine gate” making it unable to achieve pregnancy. If the depression of the liver qì is resolved and the encumbrance of the spleen qì is diffused, consequently, the qì of the heart and the kidney will also be soothed. Therefore, the waist and navel will become uninhibited, freeing the controlling vessel. The uterine vessel will then effortlessly open by itself”. The book also lists Kāi Yù Zhǒng Zǐ Tāng (开郁种子汤) (Depression-Opening Seed-Planting Decoction) for treating infertility due to jealousy.
4. Other Methods of Treatment
4.1 Acupuncture and moxatherapy
Acupuncture can treat various situations of functional infertility. As Yī Xīn Fāng《医心方》(“Heart-Treating Formula”) states, “Method for treating infertility: moxa zhōng jí xué (中极穴)(CV 3-Central Pole Point)”. The Qiān Jīn Yào Fāng 《千金要方》(“A Thousand Gold Pieces Prescriptions”) states, “The reason a woman cannot give birth is because her uterine gate is blocked. Burn 30 cones of moxa at guān yuán (关元) (CV 4-Pass Head)”. Zhēn Jiū Jiǎ Yǐ Jīng《针灸甲乙经》(“The Systematized Canon of Acupuncture and Moxibustion”) states, “As to infertility, moxa qí zhōng (脐中) (CV 8-Center of the Navel) to allow for pregnancy”. Zhēn Jiū Dà Chéng《针灸大成》 (“The Great Compendium of Acupuncture and Moxibustion”) states, “Locate the two acupuncture points of the uterus, three inches beside zhōng jí (脐中) (CV 3-Central pole). Needle the two inch-point, and burn 27 cones of moxa. This method can treat a woman who has had no offspring for a long period of time”. According to the record of Yī Xué Rù Mén《医学入门》(“The Gateway to Medicine”), sān yīn jiāo (三阴交) (SP 6-Three Yīn Intersection) is in charge of “women’s chronic menstrual irregularities and infertility”. The Lèi Jīng Tú Yì 《类经图翼》(“The Illustrated Wings of the Classified Canon”) says, “If one cannot become pregnant because of irregular menstruation, burn 3 cones of moxa at yīn jí (壮即) (LV 11-Yīn Corner) and one will surely conceive”. Ancient Chinese practitioners more often treated cases of infertility due to cold patterns than those of heat patterns. They did so by administering acumoxatherapy. It is therefore intended to administer moxa to treat patterns of cold and vacuity. Lèi Jīng Tú Yì 《类经图翼》(“The Illustrated Wings of the Classified Canon”) records, “If the woman cannot become pregnant because of blood cold, moxa shén quē (神阙) (CV 8, Spirit Gate Tower) and then miscarriage won’t happen at all”. In Yī Xué Rù Mén 《医学入门》(“The Gateway to Medicine”), the formulation used is péng zǔ gù yáng gù dì chǎng shēng yán shòu dān (彭祖固阳固蒂长生延寿丹) (“stalk securing and life-extending elixir”), which can treat the symptoms of chronic infertility and extreme uterine cold. This formula has the effect of warming yáng and boosting qì, moving qì and penetrating, quickening blood and invigorating the kidneys, dissipating cold and dispelling wind. In addition, apply a great amount of moxa. The patient will “sweat profusely”. This is precisely why it is so effective.
《干金翼方》的记载说明当时已有阴道用药治疗不孕，“女服荡胞汤，及坐药，并服紫石门冬丸，则无不得效矣。”书中还详细记载了坐导药方的组成，使用方法。《外台秘要·求子法及方》所引《经心录》茱萸丸、《女科要旨》所载“广嗣方”，均为 阴道用药治疗不孕。古代还有“兜肚方”治疗不孕的记载，出自《医学入门》与《古今医统》两书，分别日：“久不受孕者，惟有孕者忌之”“兼丹田、神阙，令人有 子”。《古今医统》载有“保真种子膏”，将此膏“贴。肾俞，暖丹田，子午既济，百病自除，一膏能贴六十日，金水生时，用功即孕，大有奇效”，“贴六十日揭去，入房即孕”。
4.2 External method of treatment
The recording in Qiān Jīn Yì Fāng《干金翼方》(“Wings of the Thousand Gold Pieces Formulary”) illustrates that during this period, applications of external medicinal baths had been used to treat infertility. “The female won’t fail once taking dàng bāo tāng (荡胞汤) (Uterus Sweeping Decoction), together with zǐshí mén dōng wán (紫石门冬丸) (Flourite and Ophiopogon Pill). The book also records in detail the formula composition and instructions. Wài Tái Mì Yào·Qiú Zǐ Fǎ Jí Fāng 《外台秘要·求子法及方》(“Essential Secrets from Outside the Metropolis·The Methods and Formulas for Seeking Offspring”) quotes zhū yú wán (茱萸丸) (Evodiac Fructus Pill) from Jīng Xīn Lù《经心录》(“Records of Managing Heart”) to be used for cases of infertility. guǎng sì fāng (广嗣方) (Formula for Extending Descendants) is recorded in Nǚ Kē Yào Zhǐ 《女科要旨》 (“The Main Points of Gynecology”). Both of these treat infertility with the method of using external medicinal baths. In addition, dōu dǔ fāng (兜肚方) (Abdomen-Covering Formula) is also recorded to treat infertility. The formula can be found in Yī Xué Rù Mén 《医学入门》(“The Gateway to Medicine”) and Gǔ Jīn Yī Tǒng《古今医统》(“The Complete Compendium of Medical Works; Ancient and Modern”). They state respectively, “Those who cannot become pregnant for a long time will surely conceive”. They further project, “Treating dān tián (丹田) (Cinnabar Field) and shén quē (神阙) (Spirit Gate Tower) makes people pregnant”. The Gǔ Jīn Yī Tǒng《古今医统》(“The Complete Compendium of Medical Works; Ancient and Modern”), also records bǎo zhēn zhǒng zǐ gāo (保真种子膏) (True-Safeguarding Seed-Planting Paste) for external application. “Attach this paste on shèn shù (肾俞) (BL-23-Kidney Transport) to warm dān tián (丹田) (Cinnabar Field). Since selection of the zǐ wǔ (子午) (Midday-Midnight/Stem and Branch points) will have mutual benefits, once utilized, the hundreds of diseases will all be eliminated naturally”. One application can remain for up to sixty days. Once metal and water engenders, pregnancy will take place with little effort, thus proving to be extraordinarily effective.
《妇科玉尺》云：“求嗣之术，不越男养精、女养血两大关键。盖男精女血，因感而会，精成其子”，提出蓄精养血以利受孕。《褚氏遗书》提出男女双方应适龄而婚：“合男女必当其年。男虽十六而精通，必三十而后娶；女虽十四而天癸至，必二十而嫁”，其道理在于“皆欲阴阳完实，然后交合，则交而孕，孕而育，育而为子，坚壮强寿”，若“未笄之女，天癸始至，”就过早交合，则“交而不孕，孕而不育，育而子脆不寿”，指出了早婚对生育的危害性，提倡男女适龄而婚，为后世医家所认同。但婚育又要及时，不可过晚，《济生方》言：“男女婚姻，贵乎及时，夫妇贵乎强壮，则易于受形也”，并提倡调情志，节嗜欲，言：“女子应养血抑气，以减喜怒，男子益肾生精，以节嗜欲⋯⋯阴阳和平，则妇人乐有子矣。”《万氏妇人科》提出节欲以养 精：“故种子者，男则清心寡欲以养其精，女则平心定气以养其血。”《女科准绳》引袁了凡言：“天地生物，必有氤氲之时，万物化生，必有孕育之时⋯⋯凡妇女一月经行一度，必有一日氤氲之候，于一时晨间⋯⋯此的候也⋯⋯顺而施之则成胎矣。”指出欲受孕者，当交合有时。《性原广嗣》云【4 J：“凡夫妇交会之际，勿嗔怒而骄傲，勿醉饱，勿用房术，勿动邪恶之心。”告诫世人交合时要选择好时间、地点，要有好心情，男女融洽，自然而然，尤其强调不用房术，在四季、阴阳、寒暑、雷霆风雨变化时，对男女双方的心理和生理上产生影响，情绪受到干扰导致脏腑功能紊乱，对受胎不利。
5. Prevention and Regulation
Fù Kē Yù Chǐ 《妇科玉尺》(“The Jade Ruler of Gynecology”) states, “The way to seek descendants does not require more than two key points: men need to nourish their essence and women need to nourish their blood. Males’ essence and females’ blood will come together because of this interaction. It is the essence that makes the child”. The book puts forward the opinion that essence-amassment and blood-nourishment is primary to pregnancy. Chǔ Shì Yí Shū 《褚氏遗书》 (“Chǔ’s Collected Writings”) puts forward the idea that a man and a woman should marry at the correct age. “The male and the female must start sexual intercourse at the correct time. Although, starting to produce essence at the age of sixteen, a man must wait to marry until the age of thirty; even though the first menstruation arrives at the age of fourteen, a woman must wait to marry until the age of twenty”. This is because “if waiting to begin sexual intercourse until after both yīn and yáng are completely mature, the intercourse will be able to lead to pregnancy, the pregnancy can lead to childbearing, and the child will be strong and long-lived”. If “the under age female begins to have sexual intercourse at the time of the first menstruation”, “the intercourse cannot lead to pregnancy, the pregnancy cannot lead to childbearing, and if it does, the child will be fragile and short-lived”. The book points out the perniciousness of marrying too early in regards to childbearing, and advocates that both males and females should marry at the appropriate age. This idea has been widely accepted by physicians of later generations. Although marriage and childbearing should occur within an appropriate amount of time, it should also not occur too late. Jì Shēng Fāng《济生方》(“Life-Saving Formula”) states, “Marriage is valued for its timeliness, husbands and wives are valued for their robustness, which allows for ease in obtaining pregnancy”. The book also advocates to regulate one’s affect-mind and to control one’s sensual desires, “Females should nourish blood and repress qì in order to reduce excess joy and anger; males should boost the kidneys and engender essence in order to control sensual desires. If yīn and yáng are calm and harmonious, a woman will happily conceive.” Wàn Shì Fù Rén Kē 《万氏妇人科》(“Wàn’s Gynecology”) holds that essence should be nourished by controlling one’s desires: “the male should be pure of heart and have few desires in order to nourish his essence, the female should keep the heart and mind calm in order to stabilize her qì and nourish her blood.” Nǚ Kē Zhǔn Shéng《女科准绳》(“The Level-Line of Gynecology”) quotes from Yuán Liǎowán (袁了凡), “There must be a time of yīn-yáng interaction for the generation of heaven and earth. There must be a time of pregnancy for the transformation of the ten thousand things of creation. All women, who have regular monthly menstruation, must have one day of ovulation, which happens within a two-hour period. This is the period of ovulation. Taking advantage of this period of time for sexual intercourse leads to pregnancy.” This quotation points out that those who desire to conceive should have sexual intercourse at a very distinct and appropriate time. Xìng Yuán Guáng Sì《性原广嗣》(“The Principle of Sex and Descendants Extention”) states, “While having sexual intercourse, the husband and wife should refrain from anger and conceit. They should not be drunken and full. They should refrain from the use of fáng shù (房术) (intercourse techniques). They should also take care as to not have evil thoughts.” This exhorts couples to have intercourse at a good time and a good location. Both individuals should be in a happy mood, be on good terms, and maintain a natural approach, and absolutely refrain from using fáng shù (房术) methods. Also, sexual intercourse, in relation to the changing of the four seasons, yīn and yáng, cold and heat, thunder and lightening, wind and rain, are likely to affect the psychology and physiology of both men and women. Disturbed emotions are likely to result in the dysfunction of the bowels and viscera, which is unfavorable for pregnancy.
Fertility is directly related to the happiness of every marriage and every family. It can be furthered considered a worldwide health issue. The causes of infertility are various and complicated. The ancient physicians, with their accumulated experience, established and put forth their original theories. Clinically, excluding those with genetic physiological defects, the treatment of infertility is mainly based on pattern identification. The best approach is to utilize the experience of the ancient physicians as a reference and comprehensively consider various factors. Treatment should be aimed to improve the state of the whole body, regulate both the internal and external, and treat both the body and mind, so as to attain the goal of conception and maintain a healthy pregnancy.