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Treating Blood & Jing in Male Fertility

This article was originally published June, 2024

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Infertility is clnically defined in women and men who cannot achieve pregnancy after one year of having intercourse without using birth control, occurring in approximately 15% of heterosexual couples who are trying to conceive. According to the National Institutes of Health, one-third of infertility cases are caused by male reproductive factors, one-third by female reproductive issues, and one-third by both male and female reproductive issues or by indeterminate factors. In the first five years of my private practice, for 40% of cases in which I was asked to help couples conceive, the primary cause of infertility was due to conditions present in the male. I was fortunate to have a gynecology teacher during acupuncture school who insisted that in every case of infertility the male was required to undergo semen analysis before beginning treatment for the couple. For an excellent and thorough discussion about both biomedicine and traditional Chinese medicine theory regarding male factor infertility, see Will Maclean’s article discussing Male Factor Infertility. In addition, a comprehensive article that you may want to share with your patients regarding all aspects of sperm production can be found on the Medical News Today website.

Each of the formulas mentioned in this article are available as templates in Mayway’s Dispensary Service (available to practitioners and TCM students). Before suggesting herbal treatment protocols, here are some other factors to consider. Apparently, male factor infertility is a growing problem, not only in the US, but also globally. While it is true that older men are likely to have a greater percentage of sperm with lower motility and abnormal morphology, according to World Health Organization statistics, the average sperm count in all men has dropped by 65% – from 113 million per milliliter in 1940 to 39 million per milliliter in 2021. Semen volumes have also decreased, while the number of men with low sperm counts (less than 20 million per milliliter) has tripled from 6 to 18%. The more recently a man was born, the lower the average sperm count and the greater the percentage of abnormalities. Many of the factors described in Maclean’s article are artifacts of modern society including pharmaceutical and recreational drugs, environmental toxins in the food, air, water, and households, and increasingly, obesity. Any of these factors may alter the normal functioning of the hypothalamus-pituitary-gonadal system and diminish a man’s testosterone, which is absolutely required for normal spermatogenesis and healthy, mature sperm that can fertilize an egg.

Normally, spermatogenesis in the testis takes around 60 days, but these sperm lack motility and fertility. Next, the sperm travel to the epididymis where the maturation of the sperm requires an additional 14 days, during which the epididymis acts as a storage vessel. During emission, sperm flow into the vas deferens where they are mixed with fluids secreted by the prostrate and seminal vesicles prior to the ejaculation of the mixture, which is now semen. It should be noted that a source of permanent male infertility/contraception is a vasectomy, in which a man’s vasa deferentia are cut and tied or sealed to prevent the sperm from the testes from entering the ejaculate.

graphic showing a healthy male testicle and varicocele

Varicoceles

The number one major cause of all male factor infertility is the presence of a varicocele in the scrotum of men. Studies have determined that 40% of males have some degree of varicocele and 16% of infertile males have a significant varicocele. A varicocele is an abnormal enlargement of the veins that remove oxygen-depleted blood from the testicles. Although the precise etiology of varicocele formation is not completely understood, at least 78% of varicocele cases involve the left testicle and may be a result of venous physiology and, interestingly, clothing or underwear choices that impinge one testicle over another. Spermatogenesis performs optimally when the temperature is below the normal physiological range. Although arguably more vulnerable, this is a design feature of the testes’ location outside the abdomen so that the temperature is cooler. When there is a varicocele, the blood pools in the veins disturbing the normal circulation, which not only inhibits the normal oxygen-carbon dioxide exchange, but also causes an increase in the scrotal temperature. Additionally, research has shown that the presence of a varicocele causes apoptosis of germ cells in the testes, which leads to decreased mature sperm production and possibly azoospermia. Varicoceles usually form during puberty and develop over time, becoming more pronounced with age. While they may result in no symptoms or complications including infertility, there may be some discomfort, achiness, or pain and in some individuals a palpable mass may form.

In biomedicine, confirmation and differential diagnosis is performed. If it is determined through semen analysis that infertility is occurring and a varicocele is present, surgery may be recommended, which can correct the issue resulting in eventual normal function or a significant improvement in sperm quality, at least sufficient for in vitro fertilization success.

In traditional Chinese medicine, a varicocele is an obvious case of Qi and Blood stagnation, predicating the principle of invigorating the Blood, dispelling Blood stasis, moving Liver Qi, alleviating pain (if any), and dissolving masses (if any). One herbal formula that may assist in such a case is Ge Xia Zhu Yu Tang.

Drive Out Stasis in the Lower Chamber Pills/ Ge Xia Zhu Yu Tang

Botanical Name Pin Yin Dose Range % of Formula Herb Action(s)
Radix Angelicae Sinensis Dang gui 6-12g 13% Tonifies, invigorates and harmonizes the Blood, reduces swelling and other symptoms associated with Blood Stasis.
Semen Persicae Tao ren 6-12g 13% Breaks up Blood Stasis, invigorates the Blood, for pain due to Blood Stasis.
Flos Carthami Hong hua 6-12g 13% Invigorates the Blood, opens the channels, dispels Blood Stasis, and alleviates pain.
Radix Linderae Wu yao 6-12g 13% Moves Qi, alleviates pain and disperses Cold, Unblocks Qi in both the Qi and Blood levels, releases constraint from the Liver and Gallbladder, descends Qi in the abdomen and warms Qi which has been slowed by pathogenic Cold.
Rhizoma Chuanxiong Chuan xiong 6-9g 9% Invigorates the Blood, moves Qi, alleviates pain, for Qi Stagnation combined with Blood Stasis.
Cortex Moutan Mu dan pi 6-9g 9% Cools Heat in the Blood, Clears Liver and deficiency Fire, Invigorates Blood and dispels Blood stasis, Reduces swelling.
Radix Paeoniae Rubra Chi shao 6-9g 9% Invigorates the Blood, dispels Qi and Blood Stasis and relieves pain due to Qi and Blood Stagnation.
Rhizoma Cyperi Xiang fu 3-12g 7% Spreads and regulates Liver Qi and alleviates pain. Treats Liver Qi Stagnation and Blood stasis with pain anywhere in the body.
Fructus Aurantii Zhi ke 3-9g 6% Moves Qi and reduces hardenings.
Rhizoma Corydalis Yan hu suo 6g 4% Invigorates the Blood, moves Qi and alleviates pain.
Radix Glycyrrhizae Gan cao 6g 4% Moderates spasms, alleviates pain and moderates and harmonizes the harsh properties of other herbs.

The formula is also available as Plum Flower™ Stasis in the Lower Chamber Teapills and in an extract powder form, Plum Flower™ Ge Xia Zhu Yu San. Both variations include vinegar-fried Resina Boswellia (Ru xiang (cu) and vinegar-fried Resina Commiphora (Myrrh) (Mo yao (cu), which provide additional actions to invigorate the Blood, dispel Blood Stasis, alleviate pain, and reduce swelling.

Jing/ Essence Issues in Male Factor Infertility

In Chinese, the word for semen and Essence is the same, “Jīng” (精). Essence is responsible for our fertility, along with our growth, development, and the physical decay of our bodies. Essence is associated with our basic constitution, strength, vitality, and the fundamental resistance of our body to various stressors and diseases. Jing/ Essence is aptly named as that which is essential to be human. It is inherited from our parents, and the amount and the quality of Essence we received is fixed from birth. In males, this Essence is transferred to our offspring via the sperm in semen. It controls reproductive function, fertility, conception, and pregnancy. Sterility/impotence, and genetic disorders are all symptoms of Essence Deficiency (Shèn Jīng Xū 腎精虛).

graphic showing several sperm and an egg

In TCM theory, two types of Essence/ Jīng are defined. Pre-natal (or pre-Heaven) and post-natal Jīng. Pre-natal Jing is passed at conception from the parents to the fetus, which nourishes the fetus with the addition of the Qi (especially her Kidney Qi) from the mother. In theory, very little can alter Pre-natal Jing after birth and it is advised that Essence should be conserved and not wasted, which is accomplished by living one’s life in harmony with the Tao. Suggested strategies, including moderation in diet, work, sexual activity, and stress reduction are recommended along with adequate rest and exercise that incorporates breathing exercises such as Qi Gong or Taiji Quan. Chinese herbs can support Pre-natal Jing but cannot replace it. Instead, for issues involving Jing deficiency, one supports Qi and Blood, and since the Kidney ‘stores’ the Jing, Kidney Yin and Yang.

According to Daoist ideas, a man should avoid ejaculation to preserve/conserve his Jing. This idea is completely related to fertility. Research has shown that men who frequently ejaculate, even daily, have relatively the same sperm count as men who avoid or restrain ejaculation. However, their number of mature sperm is significantly lower due to a lack of maturation time in the epididymis, which, as already mentioned, takes 14 days. Male patients who are being treated for infertility should be advised that saving ejaculation for their partner’s most fertile time will have a greater likelihood of a successful impregnation.

Basically, the primary pathology findings of male factor infertility e.g., low sperm count, poor motility, poor liquefaction, abnormal sperm morphology, and anti-sperm antibodies, are examples of Essence Deficiency. For a patient presenting with any or all of these findings, practitioners can only support post-natal Jing. This is accomplished mainly by tonifying Qi and Yang and nourishing Blood and Yin. Here are a couple of possible herbal approaches.

Polygonum Pill/ Hé shǒu wū piàn (何首烏片)

Radix Polgonum multiflora / Hé shǒu wū (zhì)(何首烏製), also known as Fo-Ti, has been used for centuries to treat Jing deficiency. Used in its processed (zhì) form, cooked with black bean juice and yellow rice wine, it tonifies the Liver and Kidneys, nourishes the Blood and nourishes Jing. To treat male factor infertility one possible formula is (He) Shou Wu Pian. This formula was first created by Guang An Men Hospital in 1990. Originally developed to treat hair disorders such as alopecia, et al., this formula contains herbs that tonify the Yang Qi, nourish Blood, nourish Liver and Kidney Yin, and replenish Jing. This version of Shou Wu Pian is a variation of Qi Bao Mei Ran Dan (Seven Treasure Special Pill for Beautiful Whiskers) but contains more Yang Qi herbs that enhance Ming Men. Recent research has supported its use, or close variants, to treat male factor infertility issues such as low libido, spermatorrhea, and erectile dysfunction. In addition, it has been shown to improve sperm motility, morphology, and mobility in cases of deficiency of Blood and Jing.

He Shou Wu Wan/ Polygonum Pills

Botanical Name Pin Yin Dose Range % of Formula Herb Action(s)
Radix Polygoni Multiflori Prep. He shou wu (zhi) 18g 14% Tonifies the Liver and Kidneys, nourishes the Blood, and nourishes Jing.
Semen Sesame Nigrum Hei zhi ma 12g 9% Nourishes and fortifies Liver and Kidney Yin and nourishes Jing and Blood.
Radix Rehmanniae Prep. Shu di huang 15g 11% Nourishes Yin, Jing, and Blood.
Fructus Mori Sang shen 12g 9% Tonifies the Blood and enriches Yin. Liver and Kidney Deficiency.
Fructus Ligustri Lucidi Nu zhen zi 12g 9% Nourishes and tonifies Liver and Kidney Yin.
Herba Ecliptae Han lian cao 9g 7% Nourishes and tonifies Liver and Kidney Yin.
Radix Paeoniae Alba Bai shao 9g 7% Nourishes the Yin and Blood.
Radix Astragali Huang qi 16g 12% Tonifies Qi and Blood.
Radix Angelicae Sinensis Dang gui 4g 3% Tonifies, invigorates and harmonizes the Blood.
Radix Chuanxiong Chuan xiong 3g 2% Invigorates the Blood and promotes the movement of Qi.
Radix Puerariae Ge gen 6g 4.5% Raises Spleen Yang.
Ramulus Cinnamomi Gui zhi 3g 2% Warms the channels and collaterals, unblocks Yang, transforms Qi, and warms and facilitates the flow of Qi through the channels.
Radix Glycyrrhizae Gan cao 3g 2% Tonifies the Spleen, augments Qi and harmonizes the other herbs.
Fructus Jujube Da zao 10g 7.5% Tonifies the Spleen and Stomach, augments Qi, nourishes the Blood, calms the Spirit, and harmonizes the other herbs.

Five Ancestors Pills

Five Ancestors Pills (Wu Zi Yan Zong Pills/五子衍宗丸) is reputed to be the No. 1 Kidney-tonifying formula for ‘many children and grandchildren’. This formula is recorded in "The Wonderful Prescriptions for Preserving Health": "There are people who have taken this medicine for generations, and their descendants have spread and become villages." One of the meanings of Yanzong (衍宗) is ‘propagating the clan’. Not only did the father give birth to many sons, but also the sons gave birth to many sons, and the children and grandchildren filled the house. This means that the quality of the "sperm" in the family is particularly good, which can give birth to many excellent descendants.

The five ‘seeds’ formula is an updated version of Shouxian Wuzi Pill “5 Seeds to Preserve the Immortals”, a longevity health formula dating from the Tang Dynasty (608-317 CE). The original formula calls for Alma (Indian Gooseberry)/ Phyllanthus emblica/ Yú gān zi (餘甘子), which is primarily an Ayurvedic herb. The current version uses Lycium barbarum fruit Gou qi zi (枸杞子) instead, along with Cuscuta chinensis seed/ Tu si zi (菟絲子), Rubus chingii fruit/ Fu pen zi (覆盆子), Plantago asiatica seed/ Che qian zi (車前子), and Schisandra chinensis fruit/ Wu wei zi (五味子). When men take this medicine, it can replenish Essence and marrow, support Kidney Qi, and eliminate patterns of Cold and Heat regardless of the deficiency and excess patterns of the lower Jiao. Modern Chinese medicine uses "Wuzi Yanzong Pills" to treat male infertility, sexual dysfunction (impotence, premature ejaculation), prostate hypertrophy, kidney deficiency, low back pain, and chronic kidney disease. In addition, Five Ancestors Pills can detoxify ‘metal and stone’ (i.e., heavy metals and chemical substances) and remove all toxins from the body. Since ancient times, and into modern clinical practice, it is considered the best formula for improving the quality of men’s ‘seed’ (semen) and propagating heirs.

While a decoction is considered viable, the source text recommends the percentages of powdered herbs indicated in the chart below. Tu si zi is dry fried, Wu wei zi is steamed, and Che Qian zi is fried with salt before grinding into a fine powder and mixing with pure honey (90g) and sufficient water to then roll into honey pills. Dosage is 9g of pills per day taken with warm water or wine (in winter). The formula can also be made from extract granules and placed into capsules with the same dosage recommendation. The best and most convenient form of this formula, in which all the necessary processing has already been carried out, is available as Plum Flower™ Five Ancestors Teapills.

Five Ancestors Pills are often combined with Liu Wei Di Huang Wan/ Plum Flower™ Six Flavor Teapills and/or Bu Zhong Yi Qi Decoction/ Plum Flower™ Central Qi Teapills, as well as other formulas which may be indicated by differential diagnosis.

Five Ancestors Pills/Wuzi Yanyong Pills

Botanical Name Pin Yin Dose Range % of Formula Herb Action(s)
Fructus Lycii Gou qi zi 6-18g 35% Nourishes and tonifies Liver and Kidney Blood and Yin, and benefits Jing.
Fructus Rubi Fu pen zi 3-12g 17% Tonifies and stabilizes the Kidneys, astringes Jing and urine, and tonifies Yang. For impotence and spermatorrhea due to Kidney Deficiency. Enters all five internal organs and Ming men.
Semen Plantaginis Che qian zi 4-15g 9% Promotes urination, clears Damp-Heat, and clears Liver Heat.
Semen Cuscutae Tu si zi 6-18g 35% Strengthens Yang, nourishes Yin, astringes Jing and urine, benefits the marrow, tonifies the Kidneys and Liver. Considered a sacred medicine that can nourish the heart, liver, and kidneys.
Fructus Schisandrae Wu wei zi 1.5-9g 4% Tonifies the Kidneys, tonifies Qi, produces fluids, astringes Jing, and stops diarrhea and spermatorrhea.

Final Thoughts

The main take-away is that when counseling couples experiencing difficulty in achieving pregnancy, it is critically important to consider male factors in infertility and not assume that ‘the female cannot get pregnant’. While the general health of the man should be considered, a semen analysis is required. The results of this testing will guide treatment options, and Chinese medicine lifestyle and dietary advice can provide a valuable adjunctive therapy alongside Chinese herbal medicine, that may perhaps make all the difference in attaining success. A final thought is that successful couples need to be patient, to lower expectations of a quick outcome, and to allow the therapy sufficient time to change a patient’s condition.

About the Author

photo of Skye Sturgeon

Skye Sturgeon, DAOM is the Quality Assurance Manager and Special Consultant for Mayway, USA. Skye was the former Chair of Acupuncture & East Asian Medicine and core faculty member at Bastyr University, core faculty member and Faculty Council Chair at the American College of Traditional Chinese Medicine, and President and Senior Professor of the Acupuncture & Integrative Medicine College, Berkeley. Before making Chinese medicine his career choice, Skye held various positions in the Natural Foods Industry for 12 years and prior to that was a clinical biochemist and toxicologist.


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