A 31-year-old woman with a three-year history of primary infertility and premenstrual tension was successfully managed using a Liver-soothing herbal strategy combined with acupoint thread-embedding.

Case ID: CHC-0049

Case Summary

This case describes a 31-year-old woman presenting with primary infertility lasting three years, accompanied by significant premenstrual tension syndrome (PMS) including headaches and breast distension. The original report documented a conventional diagnosis of primary infertility and a TCM assessment of Infertility (Duan Xu) driven by Liver Qi stagnation and disharmony of the Chong and Ren vessels. The patient was managed through a comprehensive approach combining a modified Xiaoyao San (Free and Easy Wanderer Powder) herbal decoction with acupoint thread-embedding to soothe the Liver, regulate menstruation, and ultimately facilitate a successful full-term pregnancy.

Patient Presentation

• Patient: 31-year-old female (Surname: He).
• Main Complaint: Inability to conceive for 3 years, accompanied by premenstrual headaches and breast distension.
• History: The patient sought her initial consultation on November 12, 2021. She had been married and actively trying to conceive for three years without success. Her menstrual cycle was generally regular, occasionally delayed by up to five days. Her menstrual flow was initially scanty and resembled red bean paste (clotted and dark) before turning bright red. Consistently, one week prior to her menstruation, she experienced headaches, breast distension, irritability, and poor sleep, which gradually resolved only after her period began.

Examination and Diagnosis

• Conventional Diagnosis: Primary infertility.
• TCM Tongue and Pulse: The tongue body was dark red with a thin, yellow coating. The pulse was stringy and rapid (脉弦数).

TCM Assessment

The original practitioner interpreted the presentation as Infertility driven by Liver Qi Stagnation and Chong/Ren Disharmony (断绪 – 肝郁气滞，冲任不调).

According to the core principles of yin and yang Chinese Medicine the Liver governs the smooth flow of Qi and blood, and it has a direct relationship with a woman’s menstrual cycle. In this patient, chronic emotional or physical constraint led to Liver Qi stagnation. This trapped Qi transformed into “accumulated depression fire” (evidenced by the dark red tongue, yellow coating, and rapid pulse).

Because the Qi was blocked, blood circulation became sluggish, resulting in the dark, clotted initial menstrual flow. Most notably, as Qi naturally attempts to surge before menstruation, the existing stagnation caused an intense “traffic jam” in the Liver and Gallbladder meridians, physically manifesting as her severe premenstrual breast distension, headaches, irritability, and insomnia. This foundational stagnation and heat disrupted the Chong and Ren (Conception) vessels, creating a hostile environment for conception.

Treatment Approach

The primary treatment principle was to soothe and regulate the accumulated depression fire in the Liver meridian, while assisting in unblocking and regulating the Qi of the Chong and Ren vessels (疏理肝经积郁之火，佐以通调冲任之气). The practitioner combined herbal medicine to address the internal imbalance with physical acupoint stimulation to continuously regulate the meridians.

Herbal Formulas and TCM Therapies

• Initial Herbal Formula (November 12, 2021): A 14-herb decoction based on Xiaoyao San.
  • Soothing Liver and Clearing Heat: Bei Chai Hu (10g), Yu Jin (10g), Zhi Ke (10g), and Chi Shao (10g) aggressively vent stagnant Liver Qi, clear localized heat, and relieve the premenstrual chest and breast distension.
  • Nourishing Blood and Regulating Menses: Dang Gui (10g), Chuan Xiong (10g), and Sheng Di Huang (10g) nourish and move the blood to regulate the cycle.
  • Moving Blood and Calming Spirit: Gan Yi Mu Cao (Dried Motherwort, 10g), Chan Tao Ren (Peach Kernel, 10g), and Niu Xi (10g) unblock stasis in the lower jiao. He Huan Pi (Albizia Bark, 10g) settles the irritability and insomnia. Jie Geng (10g) and Sha Ren (5g, added later) regulate the ascending and descending Qi dynamics.
• Acupoint Thread-Embedding Therapy: To provide continuous, long-acting acupoint stimulation, 00-gauge catgut was embedded into specific points:
  • Points selected: Guan Yuan (CV4), San Yin Jiao (SP6), Ci Liao (BL32), Zu San Li (ST36), Qi Hai (CV6), Xue Hai (SP10), Gan Yu (BL18), and Ge Yu (BL17). These points collectively nourish the Liver and Kidneys, build blood, and warm the uterus.
• Dynamic Adjustments (Visits 2 to 4):
  • November 20 & December 20: Her period arrived, and the PMS symptoms (headache, breast pain) were significantly reduced. The practitioner removed Yu Jin and added stronger blood-moving herbs (San Leng, Lu Lu Tong, Hong Hua) to further unblock the Chong vessel.
  • January 16, 2022: With the Liver Qi now flowing smoothly and PMS symptoms fully resolved, the practitioner shifted focus from “clearing” to “building.” Kidney-warming and essence-nourishing herbs were introduced: Lu Jiao Shuang (12g), Gou Qi Zi (9g), Tu Si Zi (12g), Fu Pen Zi (12g), and Shu Di Huang (9g) to deeply tonify the reproductive system and prepare for conception.

Follow-Up

• After more than three months of consistent herbal treatment and acupoint therapy, the patient’s premenstrual tension completely disappeared, indicating her Liver Qi and Chong/Ren vessels were harmonized. A later follow-up confirmed that she successfully conceived and delivered a healthy baby boy at full term.

Why This Case Is Interesting (Clinical Reasoning)

The notable feature of this case is its phased approach to treating primary infertility. The original practitioner recognized that one cannot simply prescribe heavy fertility tonics to a patient whose Liver Qi is severely congested (evidenced by her severe PMS).

If Kidney-tonifying herbs were given initially, they would have worsened the stagnation, leading to more heat and more severe headaches. Instead, the practitioner spent the first two months strictly “unblocking” the Liver and moving blood using a modified Xiaoyao San. Only in the fourth consultation, after the PMS had cleared and the “traffic jam” was resolved, did the practitioner introduce the heavy, essence-building fertility herbs (Tu Si Zi, Lu Jiao Shuang, Fu Pen Zi). The integration of acupoint thread-embedding also provided a brilliant synergistic effect, offering 24/7 internal meridian regulation to support the herbal decoction.

Source Original source: Qingyuan Maternal and Child Health Hospital / Guangdong Provincial Administration of Traditional Chinese Medicine Original title: 【以案说医】曾宪进：穴位埋线联合逍遥散治疗原发性不孕症案 Practitioner: Professor Zeng Xianjin (曾宪进) Publication date: September 14, 2024 Original language: Chinese ChineseHerb.org version: English translation and editorial adaptation