What are your protocols?

When I hear practitioners talk of “protocols”, they are generally referring to a particular clinical response to match a particular clinical scenario. It is a term I have often heard used by acupuncturists to describe their stages of treatment matching each of the four weeks of the menstrual cycle when supporting fertility – often without accommodating the patient’s underlying pattern. Sometimes it is also used by herbalists who follow a particular school of Chinese medicine – especially the Shang Han or Wen Bing schools. 

There are many approaches in Chinese medicine, but whilst I appreciate that “many roads lead to Rome”, nevertheless I have found that following basic principles and applying those flexibly and with imagination create a path to better results than a rigid adherence to “formulas” and “protocols”. I should add that Zhang Jong Jing in the 2nd century and the Wen Bing scholars who followed in his wake some centuries later, mirrored the same principles. They did not prescribe rigidly, but rather shone the light on modification, insisting on treating the individual person and the person’s individual condition and emphasising differential diagnosis. For me, this was their great gift to Chinese medicine – greater than the formulas themselves. 

I tend to be a bit of a rebel and a rule breaker – and I’m one of those cooks who never measures things and is inspired by recipes rather than following them to the letter. When making bread, a friend of mine used to weigh ingredients meticulously, then throw the dough into a bowl to be mixed mechanically with a dough hook, and judge the time needed by the clock, not by the elasticity of the dough. The bread was invariably heavy and as tough as old boots. My grandmother taught me to judge the ingredients by their consistency, and to use light hands to knead the dough. I learnt from her and that approach brought great food to my dinner table and great outcomes for my patients. So, my protocol is to respond to the specific and individual needs of my patient with originality and flexible thinking – and to avoid the cliched assumptions of "damp" and "kidney deficiency" that lay cast on the path of many less effective treatment "protocols".

We need to examine our understanding of the patient’s underlying condition and its causes before deciding on the route we will take: If there is “damp”, is the damp causing obstruction? Or is it the result of obstruction? Do we need to strengthen the Spleen, dry and transform damp with warm acrid herbs, move qi, or promote urination? We also need to consider herbal choices: if there is qi stagnation, is it better to use Wu Yao, which is warm, and enters the Urinary Bladder, Kidney, Lung and Spleen channels, or is Xiang Fu a better choice, as it is neutral and enters the Liver and San Jiao (i.e. all 3 jiao) channels?

I finally retired from formal practice earlier this year and only see a few old patients who are like my old friends. Last year, however, before retiring, I took on a new patient. She was 38 years of age and had just come out of a failed relationship; she was suffering a lot of emotional hurt and was also feeling the hurt and lost opportunity of having children. So, she was on a quest to freeze some eggs to preserve the possibility of having children in the future.

The wonderful bonus of working with women who are undergoing modern fertility treatment is that we get objective feedback from the fertility tests conducted by the modern fertility specialists. This case was no exception. When “Lena” came to see me in October 2025, she was booked in to the fertility clinic in December to start a round of medication to promote egg development in readiness for harvesting in late January/early February. This would be her second round of fertility treatment. Fertility treatment five years earlier was unsuccessful, producing only 2-3 eggs that were too small for freezing. She had seen a Chinese medicine practitioner before coming to see me, but ultrasound had shown very few eggs, all of small size.  

The herb containers from the previous practitioner she brought to show me indicated that although the formula was on the right track, it was not completely refined to fit her individual presentation.

Primarily, Lena presented with Spleen deficiency symptoms harking back to her earlier history many years ago. These were aggravated by Liver qi stagnation which may have been part of her pattern for years but certainly had come to the fore in consequence of her emotional disappointment; it was not helped by her heavy workload. She also suffered poor sleep. 

Reason for seeking treatment:

Egg freezing support (mature oocyte cryopreservation, no partner)

Early history

Childhood asthma requiring nebuliser, medication – now mild, intermittent, triggered by viral illness.

2020 – 4 stimulation cycles. High number of follicles but only 2-3 eggs of small size. Possibility of PCOS (AHM 43).

2018 – Iron deficiency > fainting

Chronic constipation – not well managed by Coloxyl (no breakfast, low intake of vegetables)

Takes a multivitamin tablet + Coenzyme Q10.

Previous treatment

She had seen a Chinese medicine practitioner in the past with no appreciable improvement. It was interesting to note that he had used a “harmonising” formula based on Xiao Chai Hu Tang, which addresses the Shao Yang. He had used the five main herbs from the Xiao Chai Hu formula and added nine herbs that a) nourished and moved blood, b) drained damp by promoting urination (cold, neutral, bland) and c) dried and dispersed damp (hot acrid). It was not incorrect to use a harmonising formula, but a better choice might have been to focus on harmonising Wood and Earth, Liver and Spleen, which fitted better with her presentation. Whilst Xiao Chai Hu Tang addresses Liver Qi stagnation, that is not its focus.

The patient presented with a Wood Earth disharmony and Xiao Yao San is the guiding formula. It is an elegantly balanced formula that harmonises Liver and Spleen. Of the six principal herbs, three are for the Liver and three for the Spleen. Chai Hu is cool and dispersing to mildly address stagnation and the heat generated. Dang Gui and Bai Shao nourish, soften and relax the Liver. Bai Zhu, Fu Ling and Gan Cao strengthen and support the Spleen. Da Zao nourishes the Spleen and Heart-shen, while Sheng Jiang assists by countering its cloying nature. The addition of Mai Dong and Zhi Shi supports those principals. 

Discussion of Harmonising Formulas

Harmonising formulas generally fall into 4 categories

1. Shaoyang formulas that clear pathogenic heat and resolve stagnation in the Shaoyang channels. The most famous is Xiao Chai Hu Tang.

2. Formulas that harmonise the Liver and Spleen. The most famous is Xiao Yao San.

3. Formulas that harmonise the Stomach and Intestines such as Ban Xia Xie Xin Tang and Huang Lian Tang.

4. Formulas that treat malaria by venting pathogens from the membrane source (Mo-yuan 膜原). These include Jie Nue Qi Bao Yin and Qing Pi Tang.

Oct 24th Current presentation

Menstrual history: Last period early Oct. No significant pain. No HA. Relatively light (pads changed every 4 hours). A few tiny clots. Stopped OCP in Aug - period returned 5 weeks later – very light. Nothing since. No hormone tests planned. Treatment will commence Dec. 

Constipation – takes Coloxyl – still not good – 2/week. Got worse this year – only 1/week this year – can start hard, finish loose. Recently gas and bloating. Advised more veg, kimchi, probiotics.

Tongue: Large, purple, thin white coat (she scraped it but not much comes off). Mod blue s/l.

Pule: tight, slow

Diagnosis: Qi stagnation, Spleen Xu

Treatment principle: Disperse stagnation and soften Liver, strengthen Spleen, stabilise Kidneys and support Essence.

Formula: The six main herbs of Xiao Yao San plus four others: Shan Yao and Shan Zhu Yu were added to support and preserve the Kidney Essence. (Research has shown Shan Yao to support female reproductive hormones). Mai Dong was used for the dual purpose of nourishing the Shen and softening the stool. A small amount of Zhi Shi was added to promote peristalsis and resolve constipation. This is a balanced formula with no extreme actions; the additional herbs do not change the character of the base formula. 

Herbs: Chai Hu, Bai Zhu, Bai Shao, Dang Gui, Shan Yao, Shan Zhu Yu, Mai Dong, Zhi Shi, Fu Ling, Gan Cao

Over the next three months, similar formulas were dispensed in line with the treatment principle. Modifications were made in accordance with her presentation, where she disclosed anxiety and poor sleep patterns.

• Other herbs used from time to time: Sheng Di, Shu Di, Da Huang, Tu Si Zi, Yin Yang Huo, Nu Zhen Zi, Ye Jiao Teng, Wu Wei Zi, Mu Li. Da Huang was provided in a separate sachet for occasional self-administration of tiny doses in recognition of the variability (sometimes 4/week, sometimes only once). That changed when she started eating more vegetables some weeks into treatment.
• In early December, she reported waking more refreshed. Her period came and she commenced taking the OCP for down-regulation as part of preparation for egg collection in February.
• From January, in order to give greater focus to the Spleen to build energy reserves that would be drained by the proliferative processes caused by the fertility treatment, I omitted Chai Hu and used Huang Qi as the chief herb, thus focusing on tonification rather than harmonisation.

Outcome:

Scan for eggs on 6th February showed 20 large (22mm) follicles on one side, as well as some smaller ones (10-12mm). Egg collection took place on 11th February when 27 eggs were collected – 20 were selected for freezing.