Manifestations: Unable to get pregnant after years of trying, menstruation either coming too early or delayed, the amount of menses is not consistent, or severe cramping during menstruation; irritation an emotional swings before menses starts, hypochondriac pain or breast distention, accompanied by frequent sighing. The tongue can be dark red, or with purple patches on the ring of the tongue, because Liver Qi stagnation can usually lead to Blood stasis. When the Qi is not flowing smoothly and propelling the blood flow, it is easy to form blood stasis. However, the tongue can show no obvious signs of abnormality, for instance, when the Qi stagnation is not severe enough to cause Blood stasis. The tongue can also be pale, because when Qi stagnates, it will impede the Liver’s function of storing blood, such patients usually also have problem with sleep due to Liver blood deficiency. The tongue can also show teeth marks, which are usually seen in Spleen Qi deficiency type. Because Liver Qi is restricting the Spleen, resulting in Spleen Qi deficiency if left untreated over a long time. Long term Liver Qi stagnation can transform into Liver fire, in which case the red tongue with thin yellow coating can be seen. The pulse is usually thin and wiry. Wiry pulse indicates Liver Qi is suppressed, not flowing smoothly, patients with PMS or when they suffer from the stress of not being able to get pregnant, it’s not hard to imagine they are stressed out, so the pulse is usually wiry.
Treatment principles: The treatment principles are to sooth Liver Qi, regulate blood and menstruation. Dr. Ye Tian Shi said “Liver the pre-heaven for women”, because blood is crucially important for women throughout their life cycle, as they lose more blood than men in general, including during menstruation and labor. In Jing Yue Quan Shu, it pointed out “women’s prosperity mainly relies on blood, when blood is abundant, menstruation will be regular, and the woman will be fertile.” 
Herbal formula and analysis: Kai Yu Zhong Yu Tang by Dr. Fu Qing Zhu, usually seen in hyperprolactinemia
The basic formula to treat infertility in this pattern is Kai Yu Zhong Yu Tang （conceptive decoction by soothing the Liver）by Dr. Fu Qing Zhu from Qing Dynasty. The herbs in this formula include: Dang Gui 15g, Bai Shao 30g, Bai Zhu 9g, Fu Ling 15g, Tian Hua Fen 6g, Dan Pi 9g, Xiang Fu 9g
In this formula, Bai Shao has the biggest dosage, it’s used to soften Liver and calm down Liver, as the emperor, together with Dang Gui, the deputy, they tonify the blood; Bai Zhu tonify Spleen Qi, Fu Ling tonify Spleen Qi and calm down the Heart. When treating Liver Qi stagnation, tonifying the Spleen is very important, because it prevents Liver Wood restricting the Spleen Earth. Xiang Fu is moving the Qi, used as the one important herb when handling depression; Mu Dan Pi is to clear the suppressed fire, accompanied with Tian Hua Fen to moisten the dryness and generate body fluid. This formula is transformed from the famous Xiao Yao San. The formula looks very simple and gentle, nothing surprising and nothing aggressive, but it is very considerate with focus on nourish the Liver and sooth the Liver Qi. Liver itself is a Yin substance, but its functions belong to Yang. When the Liver is nourished, the Liver Qi will be smoothened, and the fundamental problem of infertility in this pattern is tackled. 
Infertility in Liver Qi stagnation pattern is usually seen in patients diagnosed with hyperprolactinemia. hyperprolactinemia is the presence of abnormally high levels of prolactin in the blood. Prolactin is a peptide hormone produced by the anterior pituitary gland that is primarily associated with lactation and plays a vital role in breast development during pregnancy. Hyperprolactinemia may cause galactorrhea (production and spontaneous flow of breast milk) and disruptions in the normal menstrual period in women and hypogonadism, infertility. Irregular menstrual period is often seen in hyperprolactinemia, which from TCM’s perspective, is closely related to the regulation of Liver Qi. 
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