Although uterine tubal lavage has been commonly used clinically for a long time because of the advantages of simple equipment, convenient operation, and low price, the following drawbacks have been revealed in long-term use: 1, uterine tubal lavage is performed by injecting liquid into the uterine cavity with a catheter, and the volume and surface area of the uterine cavity is much larger than the cross-sectional area of the catheter and tubal cavity. According to the fluid dynamics principle, the pressure is equal to the pressure of the force area, so the pressure of the injected liquid into the fallopian tube is very limited; 2. In actual clinical work, we also found that the misdiagnosis rate of hysterosalpingography is high, reaching more than 50%, which can neither determine the site of tubal obstruction nor clarify the severity and nature of tubal obstruction, and there is a risk of tubal rupture and haemorrhage like ectopic pregnancy; 3. If the tubal adhesions are mild, they will be restored by hysterosalpingography. If hysterosalpingography cannot restore the tubal adhesions, then hysterosalpingography will not have any effect; 4. The site and nature of tubal obstruction cannot be clearly identified, which is not helpful in determining the treatment method and efficacy of tubal obstruction. My personal experience: frequent lavage is also a non-negligible cause of pelvic inflammatory disease and endometriosis! Patients with suspected tubal obstruction are advised to undergo direct tubal iodine oil imaging. I think the following types of people can be considered for tubal imaging: history of scraping; history of recurrent vaginitis; history of laparotomy; history of dysmenorrhea; normal ovulation and normal male partner who has not conceived for a long time.
1. Inflammation
Postpartum (or after cesarean section or abortion), gynecological surgery, unhygienic menstrual period, direct spread of inflammation in neighboring organs, etc.
About 60% to 70% of patients with secondary infertility have a history of abortion, and about 10% of patients have pelvic inflammatory disease after abortion. The incidence of tubal infertility after one, two and three episodes of pelvic inflammatory disease is 12%, 23% and 54%, respectively. The risk of tubal infertility was 4.8 times higher in patients with a previous history of appendicitis perforation. More than half of the patients will develop pelvic adhesions after pelvic surgery.
2. Tuberculosis
About 5-10% of chronic tubal infections are tuberculous. Tuberculous tuberculosis mostly originates from pulmonary tuberculosis infection and often occurs in adolescence. In patients with primary infertility and tubal obstruction, the possibility of tuberculosis should be considered.
3. Sexually transmitted diseases
In foreign countries, the main pathogens of pelvic inflammatory disease are gonorrhea, Chlamydia trachomatis and mycoplasma.
In recent years, the incidence in China has also been increasing. This pathogen infection has mild clinical symptoms and serious damage to the fallopian tubes and should be given high priority. It should be tested as routine when available.
4. Endometriosis
Ectopic endometrium invades the fallopian tubes to form nodular tubal inflammation, which stiffens and straightens the fallopian tubes and affects egg picking and delivery functions. Ovarian endometriosis cysts adhere and compress, resulting in mechanical obstruction of the fallopian tubes.
The fallopian tubes are the place where sperm and eggs meet and are fertilized, and they are also the channel for transporting fertilized eggs to the uterine cavity. Tubal obstructive infertility is mainly associated with inflammation, tuberculosis, sexually transmitted diseases, and endometriosis.
Traditional Chinese medicine.
The fallopian tubes are not only a channel connecting the ovaries and the uterus, but also have the functions of ovulation, egg storage, sperm delivery, providing a place for sperm-egg union, and transporting pregnant eggs to the uterine control in order to reach the endometrium of the official cavity in time. If there is inflammation in the fallopian tubes, resulting in blockage of the tubes, the infertility caused by the inability of sperm to pass and meet the egg is called tubal obstructive infertility. Chinese medicine has its own special method in treating tubal obstruction infertility. The following is a description of the TCM method of treating tubal obstruction infertility.
The development process of TCM evidence-based treatment of tubal infertility can be divided into three stages as follows.
Stage 1: There is no disease name related to tubal obstruction in the literature of traditional Chinese medicine, focusing on systemic identification and insufficient understanding of local lesions.
The second stage: further understanding of the disease with the help of western medical examination methods and pathological changes. Localized pathology was added on the basis of systemic identification.
Stage 3: It was determined that the combination of systemic identification and local identification of the fallopian tubes is the main method for the treatment of tubal obstructive infertility.
The treatment of tubal infertility in TCM can be divided into: internal and external treatment methods.
(1) Internal treatment method: It refers to the typological treatment combining local identification of disease and systemic identification of evidence.
(1) Local identification of disease: Because of the different causes of tubal obstruction (inflammatory, tuberculosis, endometriosis, etc.), the local manifestations of tubal lesions and the degree of lesions are also different. Inflammatory obstruction is considered by TCM as stasis of blood blocking the blood vessels; tuberculous obstruction is considered by TCM as heavy evidence of stasis of blood blocking the blood vessels; tubal effusion is considered by TCM as stasis of dampness intertwining with the blood vessels; endometriosis is considered by TCM as blood stasis and obstruction of the mass.
Local identification is to identify the cause of the disease and select targeted drugs for anti-inflammatory exudation, anti-tuberculosis, elimination of effusion and dissipation of Y and reduction of adhesions, so that the treatment can be more targeted and the efficacy more satisfactory.
2. Systemic identification: On the basis of local identification, the patient’s pathogenesis, systemic symptoms, gynecological examination, tongue and pulse are combined for identification and typing. The treatment can be divided into: internal and external treatment with Chinese medicine.
(1) Internal Chinese medicine.
(1) Liver stagnation and blood stagnation.
Main symptoms: Infertility after marriage, depression, sighing, pain in the abdomen and breasts before menstruation, irritability, low menstrual flow, dull color, poor menstruation.
Low menstrual flow, dull color, poor menstrual flow. The tongue is normal or slightly dull, and the pulse is thin and stringent.
Gynecological examination: pelvic cavity mostly normal, or thickened adnexa, pressure pain not obvious.
Treatment: De-stress the liver and activate blood circulation.
Radicals: Si Wei San with added flavor.
Radix Bupleurum 10g, Citrus Aurantium 10g, Radix Paeoniae 15g, Radix Glycyrrhiza Uralensis 10g, Salviae Miltiorrhizae 30g, Hypericum perforatum 10g, Stachybotrysum 10g.
Saponaria 10g, Wang Bu Liu Xing 15g
Addition and subtraction: If premenstrual breast distension is obvious, add Silphium 10g and Green Peel 10g.
In case of obvious distress, add Dan Pi 10g, Fried Gardenia 6g.
In cases of irregular menstruation, dull color of menstruation, with blood clots and sometimes high and low volume, add 10g of Radix Achyranthes bidentata and 10g of Rhizoma Chuanxiong.
② Evidence of internal obstruction of Blood stasis.
Evidence: Infertility after marriage, pain in the abdomen, aggravated by menstruation, menstrual flow is more or less frequent, dull in color, with blood clots.
The tongue is dull, with petechiae, and the pulse is sunken and stringent.
Gynecological examination: the adnexa shows striated thickening, or lamellar thickening, and there may be pressure pain.
Treatment: Invigorate blood circulation, resolve blood stasis and promote circulation.
Remedies: Gua Gua Root San with addition and subtraction.
Gui Zhi 10g, Tao Ren 10g, Radix Paeoniae 15g, Stinging Worm 10g, Pollen 15g, Radix Achyranthes Bidentatae 10g, Lutong 10g, Wang Bu Tong 10g.
Lutong 10g, Wang Bu Liu Xing 15g, Curcuma longa 30g
Addition and subtraction: For those with chest distension and depression, add 10g of Radix Aromaticus and 10g of Eucommia.
For pain in the abdomen, add 6g each of Lactation.
For thickening of the adnexa and obvious pressure pain, add 30g of Cyperus alba, 20g of Dandelion, and 3g of Panax ginseng powder (for dosing).
(3) Dampness and stasis in each other.
Main symptoms: abdominal and lumbosacral cramps, aggravated by exertion and intercourse, leucorrhea, loose stools, fat tongue, light and dull texture, slippery pulse.
Gynecological examination: cystic masses can be found in the adnexal region, or iodine oil imaging of the uterine tubes shows hydrosalpinx.
Treatment: Removal of blood stasis and dampness to clear the channels.
Remedies: Gui Zhi Fu Ling Wan with addition.
Gui Zhi 15g, Dan Pi 10g, Red Peony 15g, Tao Ren 10g, Fu Ling 30g, Leech 10g, White Mustard Seed 10g, Ze Lan 10g.
White Mustard Seed 10g, Zeilan 10g
Addition and subtraction: In cases of soreness and pain, add 30g of Atractylodes Macrocephala and 15g of Atractylodes Macrocephala.
For leucorrhea, add Che Qian Zi 10g, Ze Xie Di 10g.
If cystic masses can be found in the adnexal region or hydrocele in the fallopian tubes, add Verbena 15g and Euphorbia 3g.
For tuberculosis of fallopian tubes, add 15g of Xia Gu Cao and 5 centipedes.
Cold clotting and blood stasis.
Main symptoms: late menstruation, low menstrual flow, or abdominal pain during menstruation, dull color of menstruation, blood clots, cold pain in the lower abdomen, relieved by warmth, loose stools.
Pale tongue, thin white coating, sunken or sullen pulse.
Gynecological examination: posterior position of the uterus, poor mobility, painful nodules and pelvic masses can be found in the posterior vault.
Treatment: Warming the menstruation and dispersing cold, dispelling blood stasis and clearing ligaments.
Radix: Yang He Tang with Addition.
Radix Rehmanniae 10g, Antler Gum 10g (melted), Dry Ginger 6g, White Mustard Seed 10g, Ephedra 6g, Radix Glycyrrhiza Uralensis 10g, Cinnamomum Cassiae 10g, Hypericum perforatum 10g.
Cinnamon 10g, Andrographis paniculata 10g, Lulutong 15g
Addition and subtraction: If the amount of discharge is high and the stool is thin, add 15g of Atractylodes Macrocephala and 30g of Poria.
In case of kidney yang deficiency, low menstrual flow and indifferent sexual desire, add 15g of antler cream and 6g of bacopa monniera.
⑤ Damp-heat and stasis evidence.
Evidence: Infertility after marriage, pre-menstruation, or prolonged menstruation, with high volume, thick texture, bright red color, yellowish color and high volume in the lower abdomen.
Lumbosacral pain, burning sensation in the lower abdomen, especially during menstruation, dry stool, red tongue, thin yellow fur, string pulse.
Gynecological examination: thickening of the adnexa, obvious pressure pain, or inflammatory masses can be found.
Treatment: Clearing heat and eliminating dampness, activating blood circulation and promoting circulation.
Prescription: Job’s Tears and Semen Fructus with added flavor.
Raw Job’s Tear 30g, Radix Pseudostellariae 10g, Radix Sulforaphane 15g, Radix Angelicae Sinensis 10g, Radix Paeoniae Alba 15g, Radix Glycyrrhiza Uralensis 10g, Radix Pseudostellariae Sinensis 15g.
Lutong 15g, Saponaria 10g
Addition and reduction: For those with low-grade fever, add 10g of Scutellaria baicalensis and 25g of Dandelion.
In cases of heavy menstruation and dripping, add Radix et Rhizoma Cyperus 10g and Aconite 30g.
In cases of yellowish discoloration and bitterness in the mouth, add Gentiana 6g and Plantago ovata 10g.
In cases of distension and pain in the abdomen and dry stool, add Rhubarb 6g, Hou Pao 10g.
For Mycoplasma positive, add Phellodendron Bark 10g, Fu Ling 15g, Ginseng 10g, Forsythia 10g, Fleabane 10g.
In conclusion, local identification can clarify the diagnosis of the cause and enhance the target of prescriptions and medications, while systemic identification on this basis is to identify the strengths and weaknesses of qi, blood, yin and yang of the internal organs of the body through different symptoms and signs of the patient, so as to determine the corresponding treatment method and make the treatment more comprehensive and systematic.
(2) External treatment with Chinese medicine
(1) Intravenous drip of Chinese medicine: add 20ml of Danshen injection to 500ml of 5% glucose and inject intravenously once a day for 15 to 20 days, stopping during menstruation.
(2) Chinese medicine enema: absorbed directly through the rectal mucosa to reach the disease, which is conducive to the softening of local lesions and loosening of adhesions. The drug of choice for dissipating stagnation: 15g of red peony, 15g of san leng, 30g of curcuma longa, 15g of soapberry, 30g of percussive herb, 15g of cinnamon stick, 15g of wei ling xian. Decoct the above herbs to 180ml and keep the enema every night, and stop the drug during menstruation.
③ External application of Chinese medicine: Through warm stimulation and drug infiltration, it can accelerate the blood circulation of local tissues and promote the absorption of inflammation. Drug selection: 30g of Radix Rehmanniae, 6g of Radix Chuanwu, 10g of Cinnamon, 15g of Radix Wei Lingxian, 10g of Radix Angelicae Sinensis, 15g of Safflower, 10g of Salviae Miltiorrhizae, 30g of Radix Paeoniae, 15g of Sumac. Method: Roll the above herbs into granules of green beans, put them in a cloth bag, add a little white wine, steam for 40 minutes and apply to the lower abdomen. Replace the bag once a day for 2 days and stop using during menstruation.
④ Chinese medicine ion introduction: Through ion introduction instrument, Chinese medicine is introduced into the focal area to make the thickened and hardened fallopian tubes thinner and softer and restore the function of the tubes. Drug: The same as Chinese medicine enema formula. Method: Concentrated decoction of the above medicine, soaked with gauze and placed on the small abdomen, connected to the ion importer for treatment, once a day for 15 days. Discontinued during menstruation.
Experiences.
(1) Removing blood stasis without forgetting to nourish deficiency: (1) qi-activating drugs mostly consume qi, while blood-stasis-removing drugs mostly injure blood, which can easily lead to deficiency of both qi and blood over time; (2) adding qi-supplementing and blood-nourishing products, such as Radix et Rhizoma Ginseng 15g, Radix Astragali 30g, Radix Angelicae Sinensis 10g.
2. Since tubal obstructive infertility is a difficult disease to treat, it is difficult to achieve quick results. It takes 3 menstrual cycles to treat tubal obstructive infertility and the total effective rate is about 60%. It is necessary to adhere to the treatment in order to achieve the desired curative effect.
During treatment, basal body temperature should be monitored: (1) to detect pregnancy in time, stop the medication as soon as possible and switch to fetus-protective products; (2) to understand ovulation and luteal function, and add ovulation-promoting or luteal function-improving drugs appropriately to help improve the conception rate.