By Keren Zelicha & Udi Luria
Western medicine background
Poor ovarian reserve is a condition of poor infertility characterized by low numbers of oocytes remaining in the ovaries. Other familiar terms to describe this situation are “impaired ovarian reserve”, “premature ovarian failure” or “declining ovarian reserve”. Controversy and debate still exist over the definition of ovarian quality.
The common factors for the assessment of ovarian reserve are as follows:
Age is the most consistent variable that affects ovarian potential, but quite often young women in their early 30s can also show low ovarian potential. Passive tests, such as an isolated rise in serum FSH during the early follicular phase, may predict fertility outcome.1 Along with low antral follicle count (AFC) and ovarian volume, this is considered one of the predictors of ovarian failure. Women with normal FSH levels (days two to four of the menstrual cycle –10 IU/L) behave as “normal” responders and will have an adequate number of mature oocytes available for fertilization following standard ovarian stimulation.
On the contrary, patients with high FSH may respond poorly to standard ovarian stimulation both in terms of the number of oocytes and the outcome of treatment.2 It is important to note that women can have a normal follicular phase FSH level, yet still respond poorly to ovarian stimulation and hence are considered to have poor ovarian reserve.
Serum inhibin B levels can also be used to predict ovarian reserve, including egg quality and quantity. Because inhibin B is produced directly by ovarian follicles, the levels can correlate with the number of early antral follicles. An abnormal level of inhibin B, below 45 pg/mL on cycle day three, suggests poor ovarian reserve.3
Due to the knowledge gained through many previous studies, today FSH and AFC levels are the gold standard for diagnosing ovarian reserve. Other tests, like ones that measure inhibin B and anti mullerian hormone levels, are considered less reliable. If these test results are used clinically, the interpretation should be performed in the context of other clinical measures.
The most commonly used active test regarding oocyte quality and quantity is the Clomiphene Citrate Challenge Test (CCCT). In short, clomiphene citrate is given on days five through nine of the cycle and FSH levels are determined on days three and ten.
The value at day three is not stimulated and represents the same basal value used in the cycle day-three FSH screening. Clomiphene stimulates an increased release of FSH early in the follicular phase, which im- proves follicular function and when normal, the follicle would produce enough inhibin and estradiol feedback to the pituitary so as to suppress FSH production by cycle day ten. A FSH value of greater than 10 mIU/ ml for either cycle days three or ten indicates in an abnormal test. However, there is little agreement about FSH values, and criteria for normal vs. abnormal results vary from study to study.4
Since FSH is an important and reliable symptom in diagnosing poor ovarian reserve, this article will try to explain the energy, function and disharmony of FSH from the point of view of traditional Chinese medicine. With this, we can then understand how TCM can be used to treat poor ovarian response.
FSH secretion and function
FSH stimulates the growth and recruitment of immature ovarian follicles in the ovary. During the late luteal phase, estrogen and progesterone levels fall due to the degenerating corpus luteum, leading to a rise in FSH levels. This causes those antral follicles that happen to be at a more advanced stage of maturation to continue to grow. During the follicular phase, as the follicles mature they secrete estrogen and inhibin B, which leads to gradual FSH suppression via a negative feedback loop. If the follicles do not mature, FSH will continue to be produced and rise to high levels, as seen in patients going through menopause or those with poor ovarian reserve.
Chinese medicine theory
When trying to understand the energetic nature of FSH, we should look to the Nei Jing (Inner Classic) chapter one: “At the age of 14, a girl begins to have menstruation, energy in her conception meridian begins to flow, and energy in her rigorous meridian [tai Chong mai] begins to grow in abundance. At this point, she begins to have reproductive energy, which is the reason why she is capable of pregnancy.”5 Therefore follicles are related to the potential of female fertility and are part of essence. FSH is responsible for follicle maturation and growth; a fulfillment of the potential within the ovaries. Hence, FSH is related to Kidney qi energy and is considered to be yang energy.
It can be thought of as part of the Kidney- Heart Bao mai axis, as a pituitary-ovarian hormone that aids in the development of follicles. It should be emphasized that the energy of FSH relates to yuan (source) qi as well as Kidney qi. It is the qi that comes with the essence and influences the essence. Yuan qi is linked to the Kidneys and sometimes to the Ming men (life gate), expressing a movement for regulating life in the rhythmic beating between the two kidneys.6 The Kidney, Spleen, and Lung organs are very important for the production of qi and directly influence its renewal and original emanation.7 Therefore, in order to support the function of FSH to stimulate the follicles, we can strengthen the yuan qi by supporting the Kidney, Spleen, and Lung organs.
Another way of supporting the follicles is by ensuring the harmonious distribution of the yuan qi throughout the San Jiao (triple burner). The 66th difficulty of the Nan Jing (Classic of Difficulties) states that the San Jiao carries the yuan qi to the source points. It is responsible for the initiation and circulation of yuan qi from the Kidneys to the rest of the body, and promotes the functional activities of the Zang Fu and various other tissues. By supporting the distribution of the San Jiao, yuan qi can flow into the organs and support the essence of life as well as influence folliculogenesis. The distribution of the San Jiao relies on the free flow of Liver qi and the Shao yang, therefore one should also pay attention to these systems.
The importance of the San Jiao in creating life might also relate to the fact that it has no form. Formlessness is the great ancestor of matter; it is transformed by Shen to create form and life. The sense of “no form” describes the San Jiao as being the base of existence for the vital processes and the relation of life to jing (essence) and shen (spirit).8 The San Jiao connects the Heart and Kidney pathways to allow the transportation of jing and shen through the body. Maintaining the Kidney (jing aspect) – Heart (shen aspect) axis can balance the ovary-pituitary axis and regulate FSH levels. In these situations, we may observe patterns of Kidney yin deficiency, Kidney jing deficiency, Heart yin deficiency, or qi obstruction.
Zhang Jing-Yue mentioned that the San Jiao not only regulates fluids, but that it also regulates yang and has a title of “Minister of Fire.”9 He also stated that jing and shen reside in the ming men. Yang energy (ming men) is an important factor in the maturation of follicles and in transforming the potential essence into matter. Sometimes women with a yang deficiency constitution may show high FSH levels with few follicles and a low fertilization percentage.
Summary of regulating FSH functions
- Strengthen Kidney, Spleen and Lung organs in order to support the functions of yuan
Point examples: Taixi KID-3, Taibai SP-3,Taiyuan LU-9.
Herbs: Ren Shen (Ginseng Radix), Dang Shen (Codonopsis Radix), Huang Qi (As- tragali Radix), Tu Si Zi (Cuscutae Semen).
- Support the San Jiao functions of initiating and distributing yuan qi so as to promote
Point examples: Yangchi SJ-4, Shimen REN-5, Yanglingquan GB-34 with Zhigou SJ- 6, or Zulinqi GB-41 with Waiguan SJ-5. Herbs: Xiang Fu (Cyperi Rhizoma), Chai Hu (Bupleuri Radix), Zhi Zi (Gardenia Fructus).
- Support the function of the San Jiao to transport jing and shen (Kidney-Heart axis).
Point examples: Yangchi SJ-4, Waiguan SJ- 5, Zhubin KID-9, Lingdao HE-4.
Herbs: Dan Shen (Salvia Miltiorrhiza, Radix), Xiang Fu (Cyperi Rhizoma), He Huang Pi (Albiziae Cortex), Niu Xi (Achyranthis Radix).
- Support the ming men as an important factor in follicle maturation, as a yang energy and as a regulator between jing and shen.
Point examples: Mingmen DU-4, Guanyu an REN- 4.
Herbs: Rou Gui (Cinnamomi Cortex), Tu Si Zi (Cuscutae Semen), Ba Ji Tian (Morindae Radix).
Another way to understand the nature of FSH is to look at the pathological causes of its elevation:
- Genetic factors such as fragile x syndrome
- Autoimmune disorders
- Adrenal gland impairment
- Iatrogenic factors such as radiation, chemotherapy or
The above reasons relate directly or indirectly to Kidney qi and jing deficiency and can be treated by strengthening the Kidneys. These pathologies may appear in women over the age of 35 with high FSH levels. According to the seven-year cycles as discussed by the Yellow Emperor, this is the point of life when the body starts to de- cline. Therefore, by strengthening Kidney qi and jing, FSH levels may decrease.
Point examples: Taixi KID-3, Guanyuan REN-4, Qihai REN-6, Shenshu BL-23, Gao huangshu BL-43.
Herbs: Shu Di Huang (Rehmanniae Radix Preparata), Shan Yao (Dioscorea Radix), Tu Si Zi (Cuscutae Semen), Gui Ban (Testud- inis Plastrum), Lu Jiao Jiao (Cervi Cornus Colla).
Another aspect of the nature of FSH can be understood by analyzing the side effects reported by women using FSH injections during IVF and IUI treatments. By explaining these side effects, we can understand the pathologies and treatments relating to high FSH levels. The side effects can be divided into three groups:
Liver qi and blood stagnation Headaches, dizziness, and breast tender- ness. In severe cases, when ovarian hyper- stimulation syndrome (OHSS) occurs, pulmonary distress and thromboembolic events may arise. Within the framework of the six levels, these symptoms correspond to shao yang disharmony, and regulation of the pivot is needed.
Point examples: Yanglingquan GB-34 with Zhigou SJ-6, Zulinqi GB-41 with Waiguan SJ-5 (in cases with heat),10 Neiguan P-6 with Taichong LIV-3.
Herbs: Chai Hu (Bupleuri Radix), Huang Qin (Scutellariae Radix) Dan Shen (Salviae Miltiorrhizae Radix), Xiang Fu (Cyperi Rhi- zoma).
Spleen qi deficiency with accumulation of damp and fluids
Fatigue, ovarian enlargement accompanied by abdominal pain or discomfort, diarrhea, nausea, ovarian cysts and weight gain. Within the framework of the six levels, these symptoms correspond to tai yin dis- harmony.11
Point examples: Yinlingquan SP-9 with Chize LU-512, Fenglong ST-40, Taibai SP-3, Zhongwan REN-12.
Herbs: Fu Ling (Poria), Bai Zhu (Atractylodis macrocephalae Rhizoma), Shan Yao (Dioscorea Radix), Yi Yi Ren (Coicis Semen).
Kidney qi/yang deficiency causing water passage disharmony:
Adramatic increase in vascular permeability that can result in a rapid accumulation of fluid in the peritoneal cavity, thorax and potentially the pericardium. In addition, there may be thirst, scanty dark urine and ascites. These symptoms are mainly seen in OHSS.
Point examples: Shuifen REN-9, Shuidao ST-28, Yinlingquan SP-9, Lougu SP-7, Fuliu KID-7.
Herbs: Ze Xie (Alismatis Rhizoma), Fu Ling (Poria), Zhu Ling (Polyporus), Gui Zhi (Cinnamomi Ramulus), Bai Zhu (Atractylodis macrocephalae Rhizoma).
The patient was a 34-year-old female who had tried to conceive, without success, for three years. At the time her treatment began, her husband’s semen was normal but her FSH levels had fluctuated between 27 and 50 IU/L over the previous two years. Her menstrual cycle had been irregular during the previous three years. Menstruation occurred every 24-37 days and lasted for three days. Prior to trying to conceive, she was on birth control pills for seven years. The blood amount was normal, with few clots. During recent months, pale bleeding appeared mid-cycle. Dysmenorrhea occurred on the first day but was tolerable. In addition, the patient reported hyperthyroidism, cold feet, vaginal discharge and a tendency towards urinary tract infections. She had occasional night sweats and a dry mouth, but they did not affect her sleep. Her tongue was pale with a thin white coat, swollen left side and a red tip. The pulse was deep and thin.
In 2008, the patient began IVF treatments
(usually a short protocol with five ampules of Menogon and GnRH antagonist) but the response was poor with retrieval of only 1-2 follicles, and often the follicles were empty. She was told by her doctors that it would be highly unlikely that she would conceive with her own eggs.
The patient came to the clinic desperate for help, and she was frustrated and stressed by the fact she could not get pregnant with her own eggs. It was recommended that she start taking Chinese herbs and receiving acupuncture treatments on a weekly basis.
Diagnosis: Kidney qi and yang deficiency, jing deficiency, Liver qi stagnation, shen disturbance.
Treatment strategy: strengthen Kidney qi and yang, enrich jing and regulate Liver qi.
Herbal formula: Shu Di (Rehmanniae Ra- dix), Shan Yao (Dioscorea Radix), Shan Zhu Yu (Corni Fructus), Dang Gui (Angelicae Radix), Chuan Xiong (Chuanxiong Rhi- zoma), Tu Si Zi (Cuscutae Semen), Ba Ji Tian (Morindae Radix), Yin Yang Huo (Epimedii Herba), Lu Jiao Jiao (Cervi Cornus Colla), Dan Shen (Salvia Miltiorrhizae Radix), Suan Zao Ren (Zizyphi Semen), Ye Jiao Teng (Polygoni Caulis).
The formula was taken as concentrated powder at dosage of nine grams per day. Modifications were made over time but the base formula remained the same. Omega-3 pills and barley grass were also added.
Acupuncture treatments included points such as: Guanyuan REN-4, Sanyinjiao SP-6, Shuidao ST-28, Taichong LIV-3, Hegu L.I-4, Houxi SI-3, Shenmai BL-62, Taixi KID-3.
After five months of integrated treatments, the patient underwent successful egg aspiration during which two eggs were retrieved and fertilized. Acupuncture treatments were given on days one and four after egg transfer in order to improve implantation. Shortly after, it was very exciting to hear that the pregnancy test was positive and that the couple awaits a baby boy.
The patient was a 37-year-old female, who had been trying to conceive for one year. The patient reported that she had done four IVF treatments and her FSH level was 16.7 IU/L. Although she was given a high amount of gonadotropins during IVF treatments, she had only one to two eggs retrieved each time. She also had a background of hypothyroidism and therefore was taking eltroxin to regulate her thyroid. She reported that her mother and sister also had fertility difficulties and early menopause. Her cycle was regular, and the amount and color of blood and was normal. Dysmenorrhea occurred before the menses and during the first two days. Temporal headaches were common on the first day. The tongue was purple with sticky white coat in the lower jiao area. The pulse was deep and soft.
The patient was diagnosed with Kidney
qi and jing deficiency, and Liver qi stagnation with damp cold. Since there was a poor response to the high amounts of gonadotropins, the patient accepted the doctor’s advice to try natural cycles without any hormones, but with 20 mg/day of steroids and Evorel patches, which contain estradiol.
Points such as Taichong LIV-3 and Hegu L.I-4 or Waiguan SJ-5 and Zulinqi GB- 41, Fenglong ST-40, Qihai REN-6, and Guanyuan REN-4 were selected. A herbal formula called “Replenish Essence” (Kan Herb company) was given during the follicular stage. Four more IVF attempts were completed, without any result.
The continuing intake of steroids made the patient more stressed, and she had abdominal fullness and disturbed sleep. At this point the FSH level was 13.5 IU/L and a new IVF protocol of eight ampoules of Menopure was given from day three. During the follicular phase the basic formula was changed to an extracted powder containing Zhi Zi (Gardenia Fructus), Chai Hu (Bupleuri Radix), Fu Pen Zi (Rubi Fructus), Tu Si Zi (Cuscutae Semen), Shu Di (Rehmanniae Radix Preparata), Xu Duan (Dipsaci Radix), Bai Shao (Paeoniae Radix Alba), Gui Ban (Testudinis Plastrum), Yin Yang Huo (Epimedii Herba), He Huan Pi (Albiziae Cortex), Dan Shen (Salvia Miltiorrhiza Radix) and Fu Shen (Poria).
Weekly acupuncture continued with points such as Yinjiao REN-7, Guanyuan REN-4, Shuidao ST-28, Taixi KID-3 and Tai chong LIV-3. Treatment was given one day before and five days after egg transfer. The patient was asked to take a formula after transfer that included Shu Di (Rehmanniae Radix Preparata), Shan Yao (Dioscorea Radix), Dang Gui (Angelicae Radix), Chuan Xiong (Chuanxiong, Rhizoma), Dang Shen (Codonopsis Pilosulae Radix), Xu Duan (Dipsaci Radix), Tu Si Zi (Cuscutae Semen).
A few months ago, a healthy baby girl was born.
Poor ovarian reserve and high FSH levels have become a common complaint seen in acupuncture clinics. Chinese medicine has a unique diagnostic system that can contribute to the Western approach and provide effective treatment. By analyzing FSH through the lens of Chinese medicine, we can understand the treatment strategies needed to improve ovarian function, regulate hormonal secretion, and support better response to hormonal treatment. This may increase fertility outcomes.
Additional integrated studies are needed in order to determine the efficacy of Chinese medicine in the treatment of poor ovarian reserve and high FSH levels and to therefore learn more about optimal treatment for patients.
- Ahmed Kassab et (July 2007). Does measuring early basal serum follicular
luteinizing hormone assist in predicting In vitro fertilization (IVF)/ Intracytoplasmic sperm injection (ICSI) outcome?
Reproductive Biology and Endocrinology
- Toporcerova A et al .(2006). Basal concentrations of FSH (follicle stimulating hormone) as a predictor of success of IVF- ICSI cycle. Ceska Gynecol, 71 pp. 474-479.
- http://www.drmalpani.com/ htm
- Brooks Keel (2000). Handbook of the assisted reproduction laboratory. Informa Health Care
- Lu, Henry A complete translation of the Yellow Emperor’s Classic of Internal Medicine and the Difficult Classic. The International College of Traditional Chinese Medicine, Vancouver
- Claude Larre & Elisabeth Ro- chat de la Vallee, (1999) Essence, spirit, blood and qi. Monkey Press, 47.
- ibid, 49.
- Birch (2003). What is the san jiao, triple burner? An exploration. European Journal of Oriental Medicine. Vol 4, No.2, pp. 49-56.
- Claude Larre & Elisabeth Rochat de la Vallee (1992). Heart master triple Monkey Press, p. 59.
10 Wang, Ju Yi & Robertson, Jason. (2008), Applied Channel Theory in Chinese Medicine, Eastland Press, inc, p. 556.
- ibid, p. 63.
- ibid, p. 565.
- Keren Zelicha is an acupuncturist and herbalist practicing and teaching in She received her master degree of Chinese medicine gynecology at ZheJiang University of TCM in 2003. Today Keren mainly practices Chinese medicine gynecology at her private clinic and works at Davidov Integrative Cancer Center, Belinson’s Hospital. She can be contacted at:firstname.lastname@example.org
- Udi Luria is an acupuncturist and He received his diploma from Genesis College and undertook advanced studies at ZheJiang University of TCM. Today he teaches in the Tel-Aviv branch of Reidman College and practices in his clinic in Ramat-Gan, Israel. Email: email@example.com