Original title: Approaching Low Ovarian Reserve with a Chinese Medical Perspective
Interview with Dr. Ann Wang, by Mary Lambdin
Abstract
With infertility rates on the rise in the US, it’s essential to delve into different perspectives for guidance. Approaching infertility from a Chinese medical perspective has yielded promising results for Dr. Wang. She has modified historical and modern methods to deal with the prevalent issue of infertility, and specifically, low ovarian reserve. Heeding an integrative medicine approach, she has worked with a range of Western practitioners to give hope to families struggling with infertility. Inclusive of prevalent research, Dr. Wang discusses her methods for helping women bring babies to full term.
Interview
Mary Lambdin: Thank you for taking the time to speak with me today! Fertility is a topic of considerable interest and I’m excited to speak to you about how acupuncture and herbs can enhance fertility naturally, through a combination of treatment and lifestyle changes. I’d like to learn more about what Traditional Chinese Medicine (TCM) can offer to those suffering from infertility. Before we get into that, I’d like to hear more about your background as the founder of the Integrative Medicine Center in Ithaca, NY, one of the earliest practices to take an integrative medical approach in the US. Please tell me a bit more about your approach and your practice.
Dr. Ann Wang: Yes, I practiced both Western and Eastern medicine, truly “integrative medicine” when I worked in hospitals in China. When I started to practice in this country in 1994, I found that Eastern and Western medicine are very isolated from one another. I initially practiced on my own, but it was always my vision to integrate Eastern and Western, to collaborate in all aspects, in order to provide a synergistic medical model.
Then in 2002, I opened the doors to the Integrative Medicine Center, located in Ithaca, NY. At the Integrative Medicine Center, we combined acupuncture, herbal medicine, physical therapy, nutrition, chiropractic, functional medicine, and more. Over the years, we’ve had MDs, naturopaths, acupuncturists, nutritionists, chiropractors, and others. Also, the Integrative Medicine Center is home to a wonderful herbal pharmacy.
During the pandemic, I transitioned to telemedicine. I am now seeing patients virtually and offering herbal consultation to practitioners through Treasure of the East; advising and collaborating with other practitioners on herbal formulas for their patients. It’s been a big change, but I find I enjoy helping other practitioners as much as I enjoy helping patients directly.
Could you give me a bit more information on your background and specialty areas?
I hold a doctoral degree in Chinese Medicine from Shandong University of Traditional Chinese Medicine, and I’m a licensed acupuncturist, with training in both the East and the West. Chinese medicine is a general practice to help patients get to the root cause of their ailments. My specialities are in chronic illness management, pain management, and fertility. My real passion is fertility for the past couple of decades. One of the main reasons for this is because I feel that it’s a great honor to help my patients bring a healthy baby to full term. This is where a lot of my joy and fulfillment comes from!
Infertility has also become more and more common over time. Why do you think that is?
There are many reasons to explain this. One, couples are planning to have a family later in life than in decades before. Two, there are more environmental factors present such as increased hormone-use, pesticide-use, chemical pollution, and electromagnetic pollution. This tends to especially affect male fertility. More and more men are experiencing lower sperm levels due to the above reasons. At the same time, more and more women are experiencing low ovarian reserve.
So how do you deal with infertility in your practice? Did you develop the acupuncture protocol that you use for this?
The acupuncture protocol that I use in my practice is not personally developed. It’s a method developed by Dr. Zheng Guoping, who practiced in the US as a Chinese medicine infertility specialist. Her practical use is the Four Groups of Acupuncture Fertility Assisting Points, which is the method of acupuncture I have been using in my practice, with modifications according to patients’ different TCM diagnoses and menstruation phases.1
Zheng’s Four Groups of Acupuncture Fertility Assisting Points are first, to calm the mind, relax the body, and improve the blood calculation; acupoints used are Shenting (GV-24) and Hegu (LI-4). The second are the auricular points that are used to stabilize the mind, relax the body, and regulate the ovarian uterus function. Although there are four points on the list – the ovaries, uterus, kidneys, and Shenmen (HT-7) – only two points are used each time. The third group is a set of six fertility points for tonifying Chong and Ren channels and regulating the qi and blood that are supporting ovary and uterus function; acupoints used are Zhongji (CV-3), Guanyuan (CV-4), Guilai (ST-29) (bilateral), and uterus (double). The fourth group is to invigorate the kidneys and liver, regulate the blood, and strengthen the spleen and stomach function to support the ovaries and uterus; acupoints used are Taixi (KI3), Sanyinjiao (SP-6), Yinlingquan (GB-34), Zusanli (ST-36), Zhongwan (CV-12) and Baihui (GV-20).1
How did you learn about Zheng’s Four Groups? Where can we learn more about it?
I was fortunate to have learned directly from my close friend, Dr. Zheng. I combined her teachings with my own clinical experience. To learn more, it’s best to contact her directly. Her practice is based in New York City.
You’ve mentioned the long history of acupuncture and herbal medicine to treat infertility. Are herbs as effective and important as acupuncture? Do you have to use both in combination for ovarian reserve?
Although acupuncture is very helpful particularly for ovarian reserve, both a combination of acupuncture and herbal medicine use are very necessary. Chinese medicine believes that kidney deficiency and blood stasis are the cause of low ovarian reserve. In order to boost the reserve, it’s necessary to fill the vital essence, tonify blood, and regulate menstruation. To do this, herbal medicine works even better than acupuncture. A commonly used formula, called Zi Shen Yu Tai Wan, has been a thoroughly researched and effective formula for improving ovarian reserve.1
That’s quite fascinating! Please tell me more about the formula. Has it been studied for its efficacy for low ovarian reserve?
Yes. The Journal Of Shandong University of Traditional Chinese Medicine includes a 2010-2012 study of the effectiveness of using zishen yutai pills in treating ovarian reserve with weak spleen and kidney. The study consisted of 40 patients with ovarian reserve dysfunction in the gynecological clinic of the First Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine that were divided into two groups: 20 patients in the Chinese medicine group and 20 patients in the Western medicine group. The Chinese medicine group participants were administered Zi Shen Yu Tai Wan while the Western medicine group participants were administered hormone replacement therapy (HRT) in the form of Progynova and progesterone. Prior to and following three months of treatment, patients’ clinical symptoms, menstrual cycle changes, and hormone levels were observed. Both groups showed improvement following treatment, though with different indicators.2
Oh, how interesting. Can you share more detailed results from this study with our readers?
Yes, researchers who led the study, reported that low ovarian reserve patients experiencing perimenopausal symptoms observed marked improvement after treatment with Zi Shen Yu Tai Wan compared with treatment using HRT.2 Patients’ perimenopausal symptoms included lower back and knee pain, insomnia and hyperactive dreaming, fatigue, shortness of breath, and aversion to socializing. However, with regard to patients’ menstrual cycles, most of the patients recovered to normal menstrual cycles after HRT, while fewer did so after Zi Shen Yu Tai Wan.2
The hormones observed in the study were follicle stimulating hormone (FSH), luteinizing hormone (LH), estradiol (E2), inhibin B (INHB) and antimullerian hormone (AMH). The hormones FSH and AMH are indicators of ovarian reserve, while E2 is an indicator of ovarian function and egg quality. The hormone LH regulates the function of the ovaries and of the menstrual cycle, and INHB is a lagging indicator of the development of ovarian follicles.2
Researchers found that compared to patients’ hormone levels prior to treatment, patients taking Zi Shen Yu Tai Wan were observed to have improved levels of FSH and LH, but no significant change in E2. Patients taking HRT observed improved levels of FSH, but observed no significant change in LH or E2. Both groups showed improvement in their levels of AMH and INHB compared to before the treatment.2
During the two-year period of the study, 4 out of 20 patients treated with Zi Shen Yu Tai Wan became pregnant. An additional 8 patients improved significantly, while 6 patients improved, and 2 patients were observed as having no response. No adverse reactions were observed in the Chinese medicine group. In the Western medicine group, 2 out of 20 patients became pregnant, 7 patients improved significantly, 8 patients improved, and 3 patients were observed as having no response. Of these 20 patients, 3 observed breast swelling and pain and 2 observed nausea and vomiting. After statistical analysis, researchers concluded there was no significant difference between outcomes in the traditional Chinese medicine group and the Western medicine group, but that both groups showed improvement compared to indications prior to treatment.2
That’s very impressive and not many people know of this formula. Is this a modern formula or classical formula? Can you tell me about how it’s been used in China?
Zi Shen Yu Tai Wan is considered a modern formula but it’s actually based on a formula from the Qing Dynasty developed by the famous Dr. Zhang Xichun called Shou Tai Wan. In the early 1960s, Dr. Luo Yuankai, the renowned fertility doctor and cofounder of the Guangdong University of Chinese Medicine, modified the classical formula and named it Bu Shen Gu Chong Wan. Dr. Luo was later awarded by the Chinese Ministry of Public Health for his development of this formula, as well as another formula for the induction of ovulation.
Today, the formula that Dr. Luo popularized as Bu Shen Gu Chong Wan is known across China as Zi Shen Yu Tai Wan. The formula is comprised of fifteen herbs: Ti Si Zi, Sha Shen, Shou Di Huang, Ren Shen, Sang Ji Sheng, E Jiao, He Shou Wu, Yai Ye, Bi Ji Tian, Bai Zhu, Dang Shen, Lu Jiao Shuang, Gou Qi Zi, Xu Duan, and Du Zhong. In the US, you can find modified Zi Shen Yu Tai Wan under the name Fertile Tonic from the Treasure of the East.
Do you use the Zi Shen Yu Tai Wan formula to treat ovarian reserve patients in your practice? How is Fertile Tonic different?
While Zi Shen Yu Tai Wan is a widely used and effective formula, for many years I’ve used a variant of it in my practice that is specifically designed for Western patients and for those also dealing with poor egg quality. The formula Fertile Tonic is a similar formula to Zi Shen Yu Tai Wan with three modifications:
1. Added Chai Hu herbs to smooth the Liver Qi and regulate emotions for a happy and peaceful feeling during the treatment of fertility
2. Added Dan Shen to remove blood stasis in order to improve egg quality
3. Replaced E Jiao with other blood tonic ingredients
I’ve made these modifications based on the different necessities of the Western patient. For example, more Western patients are experiencing emotional distress, which affects ovarian function. For this reason, we need to add herbs to regulate emotions. I also find that more people have blood stagnation, which needs to be addressed in order to improve egg quality. Finally, a blood tonic is added to replenish the blood circulation to the ovaries. The dosage for this formula is 4.5 – 6 grams of granulated extracts, two times daily.
With acupuncture, fertility formulas such as Zi Shen Yu Tai Wan and Fertile Tonic, have been able to support patients facing infertility issues like ovarian reserves. These formulas are used to improve the quality of eggs; regulate the cycle; avoid miscarriage; and support IVF that directly relates to the delivery of a successful, healthy pregnancy.
Are these the main formulas you use with your fertility patients? Are there other formulas you believe to be important?
Actually, there are 28 formulas that I developed to comprehensively support each stage of a woman’s cycle and each stage of pregnancy, to support men, and to address common causes of infertility. These formulas are all available to practitioners from China Herb Company.
Dr. Ann Wang’s Fertility Specialty Formulas
Three Branch Approach to Reproductive Health
Branch I: Restore the Root
Fertility Preparation: Used 3-6 months prior to fertility treatment to deal with the underlying causes for each condition.
| Conditions & TCM Pattern | TCM Actions | Formula Names | Formula Number |
|---|---|---|---|
| Tubal Blockage with stagnation of Qi and Blood | Eliminates blood stasis; Opens the Chong and Ren channels | Free Channel / Xiao Liu Tang * | Formula 1 |
| Endometriosis with Kidney deficiency, Liver Qi stagnation and blood stagnation | Tonifies Kidney Yin, nourishes Kidney Qi and Yang; regulates the Liver; eliminates blood stasis | Endo Chong Ren Care | Formula 2 |
| Dysfunctional ovulation with Kidney Yang and blood deficiency | Boosts Kidney Yang and Qi; regulates blood flow and balances Chong/Ren channels | Yu Lin Fang * | Formula 3 |
| Polycystic Ovarian Syndrome with Kidney deficiency, blood stagnation, and excessive dampness | Tonifies Kidney Yang and Qi; dispels dampness; eliminates blood stasis | Pearl Release | Formula 4 |
| Habitual Miscarriage with Kidney deficiency and generalized Qi deficiency | Tonifies Kidney and replenishes Qi | Fertile Anchor | Formula 5 |
| Low sperm count with Kidney Yin and essence deficiency, deficient Qi and blood | Nourishes Kidney, replenishes Essence and strengthens blood | Male Vital Care (Zan Yu Dan) * | Formula 6 |
| Men’s Immune Infertility with Kidney Yin deficiency | Tonifies Kidney Yin and regulates immune function | Men’s Immune Harmony (Kidney) | Formula 7 |
| Men’s Immune Infertility with Liver Qi Stagnation | Harmonizes Liver Qi, regulates blood and adjusts immune function | Men’s Immune Harmony (Liver) | Formula 8 |
| Women’s Immune Infertility with Kidney Yin deficiency and excessive inner fire | Tonifies Kidney Yin, nourishes blood and regulates immune function | Women’s Immune Harmony | Formula 9 |
| Ovarian Hyperstimulation Syndrome (OHSS) with deficiency of Yin and excessive Yang, along with stagnation of Qi and blood | Treats Yin deficiency with internal heat; regulates Qi and blood; and balances the Chong Mai | Re-Balance | Formula 10 |
| Luteal phase defect with Kidney deficiency | Tonifies Kidney and boosts Qi | L-Vitality | Formula 11 |
| Low or Diminished Ovarian Reserve with Kidney and Liver blood deficiency | Tonifies Kidney and Liver; Supplements Jing and blood | Fertile Tonic * | Formula 12 |
| Irregular Menstruation with Qi and Blood stagnation and Kidney deficiency | Tonifies Kidney Yang; tonifies Qi and nourishes the Blood | Cycle Care | Formula 13 |
| Men’s Yang Support | Replenishes Essence and boosts Kidney Yang | Men’s Yang Support
| Formula 14 |
| Men’s Yin Support | Replenishes Essence and nourishes Kidney Yin to reinforce the life force | Men’s Yin Support
| Formula 15 |
Branch II: Regulate the Cycle
Nourish and Support
Deficiency Patterns: Used for deficiency patterns, including irregular menstruation, delayed or dysfunctional ovulation with Kidney Qi and Spleen Qi deficiency. Harmonizes the cycle and nourishes Shen to help optimize fertility. Treatment for 3-6 cycles before an IUI or IVF cycle is recommended.
| Condition | TCM Actions | Formula Names | Formula Number |
|---|---|---|---|
| Follicular Phase with Kidney and Spleen Qi deficiency Day 6-11 | Supplement Kidney Yin, Liver blood and regulates the menstrual cycle | Nourish 1 (Cycle Days 6-11) | Formula 16 |
| Ovulatory Phase with Kidney Qi and Spleen Qi deficiency day 12-15 | Tonifies Kidney and blood, stimulating the blood flow | Nourish 2 (Cycle Days 12-15) | Formula 17 |
| Luteal Phase with Kidney Qi and Spleen Qi deficiency day 16-end of the cycle | Tonifies Kidney Yin and Yang, Harmonizes Qi and blood. | Nourish 3 (Cycle Days 16-P) | Formula 18 |
| Menstrual Phase with Kidney Qi and Spleen Qi deficiency Day 1-5 | Regulates menstrual cycle and Eliminates blood stasis | Nourish 4 (During Menses) | Formula 19 |
Cycle regulation may overlap with IUI and IVF preparation. The purpose of Cycle regulation is to promote conception with a natural approach.
Branch II: Regulate the Cycle
Harmonize and Clear
Stagnation & Heat Patterns: Used for stagnation and heat patterns, presenting as irregular menstruation, early menstruation, and short follicular phase with a pattern of kidney Yin deficiency, Qi stagnation, and elevated heart fire. Treatment for 3-6 cycles before an IUI or IVF cycle is recommended.
| Condition | TCM Actions | Formula Names | Formula Number |
|---|---|---|---|
| Follicular Phase with kidney Yin deficiency, Liver Qi stagnation, and elevated heart fire Day 6-11 | Nourishes Kidney Yin and blood; regulates the Liver Qi; reducing internal fire and delayed ovulation | Harmonize 1 (Cycle Day 6-11) | Formula 20 |
| Ovulatory Phase with kidney Yin deficiency, Liver Qi stagnation, and elevated heart fire day 12-15 | Tonifies Kidney and blood; regulates the Liver Qi and stimulating the blood flow | Harmonize 2 (Cycle Day 12-15) | Formula 21 |
| Luteal Phase with kidney Yin deficiency, Liver Qi stagnation, and elevated heart fire Day 16-end of the cycle | Tonifies Kidney Yin and Yang; Harmonizes the Liver Qi and blood. | Harmonize 3 (Cycle Day 16-P) | Formula 22 |
| Menstrual Phase with kidney Yin deficiency, Liver Qi stagnation, and elevated heart fire Day 1-5 | Regulates menstrual cycle; regulates the Liver Qi and clearing blood stasis | Harmonize 4 (During Menses) | Formula 23 |
Branch III: IUI and IVF Support
The purpose of IUI and IVF support is to increase the success of IUI or IVF cycles. These formulas are safe for use with ART.
| Condition | TCM Actions | Formula Names | Formula Number |
|---|---|---|---|
| Women’s Support (Prior to triage short) | Regulates Liver Qi, supplements blood, harmonizes Shen, and calms the spirit. A classic formula to help manage stress. | Happy Day (Xiao Yao Wan) * | Formula 24 |
| Women’s Support (After Transfer) | Tonifies the Kidney Qi, nourishes blood, and supports implantation. | After Transfer Formula | Formula 25 |
| Women’s Support (Positive Pregnancy Test, No Spotting) | Supports the Kidney energy and nourishes the blood to maintain pregnancy | Maintenance 1 | Formula 26 |
| Women’s Support (Positive Pregnancy Test, With Spotting) | Supports the Kidney energy and nourishes the blood to calm restless fetus. | Maintenance 2 | Formula 27 |
| Morning Sickness Liver (Stomach Disharmony) | Harmonizes the balance between Liver and Stomach; reducing symptoms to help the body achieve homeostasis | Good Morning Formula | Formula 28 |
| Men’s Yang Support (Repeated from Branch I) | Replenishes Essence and boosts Kidney Yang | Men’s Yang Support Formula
| Formula 14 |
| Men’s Yin Support (Repeated from Branch I) | Replenishes Essence and nourishes Kidney Yin to reinforce the life force | Men’s Yin Support Formula
| Formula 15 |
Where to find the formulas The most commonly used formulas (notated with *) are available from Treasure of the East (https://treasureoftheeast.com) or by calling 607-275-9700. All formulas are available from China Herb Company (https://chinaherbco.com) or by calling 215-546-5870.
Very impressive. Are there any recommendations for individuals to utilize this method of acupuncture and herbal medicine treatment? What’s the typical duration of this treatment for your low ovarian reserve patient?
If used to boost ovarian reserves, improve follicular development, promote ovulation, and/or improve the quality of eggs, it is important to work with patients well in advance of pregnancy. Typically, 3-6 months are needed prior to pregnancy to invigorate the kidneys and spleen, particularly so for patients with poor egg quality.
Patients with irregular menstruation may benefit from herbs taken twice a day for 20 days, starting on the 5th day of menstruation for a period of three months, to regulate the cycle and the uterine environment, while also addressing delayed menstruation or hypomenorrhea.
If patients are threatened with miscarriage and/or recurrent miscarriage, it is important to improve luteal function and endometrial receptivity by invigorating the kidneys and spleen and nourishing the blood to stabilize the fetus.
Patients with frequent spotting, lumbar soreness, and lower abdominal pain, may benefit particularly from taking herbs 12 weeks prior to pregnancy and for the first 12 weeks of pregnancy.
Okay, this will be the last question. Do you think that acupuncture and herbal remedies will be enough? Or do you feel that collaboration with other practitioners is important?
Not only relating to low ovarian reserve, but for infertility in general, I believe that collaborative work with Western practitioners and with technological advances, is most beneficial. In the past 17 years, I’ve worked closely with IVF specialists in Central NY because I, along with many other TCM practitioners, have seen a very clear pattern with IVF patients. Those undergoing TCM treatment for ovarian reserve see better response to ovulation stimulation drugs, higher numbers of retrieved mature eggs, more fertilized eggs, more quality embryos, and higher chances of conception with each round of IVF. Even after IVF, the rates of miscarriage have been reduced.
References
- Zheng, Guoping. Special Seminar for China Earthquake Relief Fundraiser. Atcms.org. https://atcms.org/files/Seminar-6-1-08-Zheng-GP.pdf. Accessed July 7, 2021.
- Yun, S, Shenghua, Y, Lili, T, & Yuzhen Z. Clinical observation of zishen yutai pills in treating ovarian reserve with weak spleen and kidney. Journal of Shandong University of Traditional Chinese Medicine. 2013;4. http://www.cqvip.com/qk/94819a/201304/46587247.html. Accessed March 4, 2021.
