Fertility

Original Editor - Nicole Sandhu Top Contributors - Nicole Sandhu, Khloud Shreif, Kim Jackson and Franca Ebomah

Definition/Description[edit | edit source]

Infertility is the inability to conceive despite frequent coitus and unprotected intercourse for a year in women younger than 35 and 6 months for women older than 35 years, it is a disease for the female and male. Infertility refers to a state in which the capacity for fertility is diminished, but not necessarily absent. Fertility issues can be a burden in almost every aspect of life for individuals and/or couples; socially, physically, mentally, and financially. It is divided into two types; primary infertility in women who have never get pregnant, and secondary defined as the inability to get a pregnant after previously giving births.

Mother Newborn postnatal.jpg

Relationships can suffer with the spouse or partner, but also those with friends and family members. This could be due to feelings of frustration from well-intentioned, unsolicited advise that may be painful, or social isolation from family and friends who may be pregnant or have children, and feelings of stigmatised. Women will experience low quality of life and affect long-term health of their family[1]. Dealing with various outcomes while dealing with fertility issues can be very emotional. Individuals and couples can deal grief and distress after a/multiple miscarriages, or a failed IVF cycle, and overjoyed with successful attempt, regardless, the process can be long and arduous. If an individual is using medication to improve fertility outcomes, this often comes with side-effects which can affect the individual physically and mentally. Lastly, seeking medical assistance for fertility issues can be very costly and is often not covered by insurance or medical services. This is also a huge barrier to seeking assistance with fertility.[2]

Epidimology[edit | edit source]

The World Health Organization estimated about 186 million individual and about 48 million couples worldwide live with infertility. While the common cause of infertility in males is due to problems in ejection of the semen, in females there are different causes and sometimes the definite cause is unknown. According to NHS about 1 in 7 couples have difficulty in conceiving. In USA about 1 in 5 (19%) in women aged from 15-49 years are un able to concieve after one year of trying and about 1 in 4 of this group have difficulty in getting pregnant according to CDC.

Etiology[edit | edit source]

Pathology affecting fertility[3]

  • Ovulatory dysfunction: 21%
  • Tubal damage, blocked fallopian tube may be due to endometriosis, STI infection, previous ectopic pregnancy, adhesions after pelvic or abdominal surgeries represntes about 14%.
  • Endometriosis about 6%, fibroids , or congenital anomaly with the uterus.
  • Coital problems: 6%
  • Cervical factor: 3%
  • Unexplained: 28%
  • Male factor (hypogonadism, post-testicular defects, seminiferous tubule dysfunction): 26%

[4]

Modifiable lifestyle factors affecting fertility

Factors affecting fertility Information
Tobacco use
  • Has been associated with infertility, particularly if the female partner is using tobacco[5]
Weight
  • increasing obesity is associated with decreasing spontaneous pregnancy rates and increased time to pregnancy[6][7]
  • increased weight in both males and females has a negative impact on fertility[8][9]
  • a prospective cohort study found that every 5 kg body weight increase is associated with a current duration of pregnancy attempt increased by 5%[10]
  • weight loss is advised for females with an elevated BMI because weight reduction aids in spontaneous conception in some studies and reduces the need for fertility treatment[11][12]
  • the risk of unsuccessful in vitro fertilization (IVF) increases with increasing BMI and may be related to poor oocyte quality, ovarian function, endometrial quality, or a combination of these factors[13]
Exercise
  • vigorous exercises may have an adverse effect on fertility on females with a BMI <25 kg/m2, however, exercise has a positive effect fertility on females who are overweight[14]
Alcohol intake
  • moderate alcohol intake in females and males does not appear to affect fertility[15][16]
Diet
  • see below under "Diet and Fertility" resources
Caffiene
  • caffiene intake less than 200mg/day in both females and males does not seem to affect fertility[15]
Stress
  • in a meta-analysis a small but significant negative associations were found between stress, distress and reduced pregnancy chances with assisted reproductive technology[17]

Management[edit | edit source]

Physiotherapy[edit | edit source]

Although there are no specific physical therapy protocols for fertility, physiotherapists may be well positioned to assist patients with aspects of their fertility journey. The first step for physiotherapists is to become educated on the topic and aid in educating the public on the importance of exercise and weight management in fertility. As stated above weight and exercise have an effect on fertility, and physiotherapists can have a more direct role through creating and implementing an exercise program to suit the needs of their clients. Exercise is a relatively inexpensive addition to “usual care” in improving the outcomes of assisted fertilization. Additionally, exercise may aid in the mental health of clients during this challenging time. The ultimate goal is to aid individuals in reaching their fertility goals and it is important that as healthcare providers we are informative and proactive regarding the breadth of issues that could be affecting their assisted fertility outcomes. As discussed this can be a very stressful time, techniques such as mindfulness meditation, deep breathing, guided imagery, and yoga can be promoted for stress management.

A study conducted by Kiel et al. (2018), examined the effect of high-intensity interval training (HIT) on women undergoing assisted fertilization through a pilot randomized control trial. Eighteen woman with a body mass index of over 25.0 kg/m​2​ were split into two groups: the control group “usual care” (n=10) and the intervention group “HIT” (n=8). The first outcome measure was “ongoing pregnancy” and the second was “insulin sensitivity, reproductive hormones, oxygen uptake, and body composition.” The study concluded that HIT significantly improved insulin sensitivity, VO​2 ​peak, and abdominal fat. Furthermore, fertility outcomes may increase by improving insulin sensitivity and the regulating the hypothalamic-pituitary-adrenal axis, central obesity, as well as, cardiovascular fitness.[18][19]

Exercise therapy may be beneficial, however, this must be prescribed with caution in some cases as there may be an increased risk of ovarian torsion.[20] The risk of ovarian torsion increases with the presence of an ovarian mass and increased ovarian size, and individuals actively going through assisted fertility therapy (ie. in vitro fertilization), which stimulates the ovaries, increasing their size.[21][22]

Another modality that can be used is manual therapy it depends on applying specific manual soft tissue protocol that help to improve blood supply to the reproductive organs, improve lymphatic drainage, improve tissue elasticity and distensibility, mobilize the tight ligaments and break the cross links of collagen that may be present in pelvic adhesions conditions such as; endometriosis, fibroids, adhesions post pelvic or abdominal surgeries, obstructions of fallopian tubes[23], and biomechanical reproductive organ dysfunction[24]. In addition, it increase the success rate of IVF if it was carried before the procedure[25]. A recent systematic review about the role of osteopathetic therapy in gynacological and obstetric disorders it was effctive as a complementary medicine with endometriosis, pelvic pain, adhesions, and PCOS however it is effect on infertility was not reported[26].

Common conditions that physiotherapists may encounter that could affect fertility include: endometriosis, polycystic ovarian syndrome (PCOS), cancer and/or cancer treatments.

Medical Interventions[edit | edit source]

Diagnostic testes for couples with fertility issues:[27]

  • Semen analysis to assess male factors.
  • Menstrual history, assessment of luteinizing hormone surge in urine prior to ovulation, and/or luteal phase progesterone level to assess ovulatory function.
  • Hysterosalpingogram or sonohysterogram with a test of tubal patency such as hysterosalpingo-contrast-sonography to assess tubal patency and the uterine cavity.
  • Assessment of ovarian reserve with day 3 serum follicle-stimulating hormone and estradiol levels, anti-Müllerian hormone, and/or antral follicle count.
  • Thyroid-stimulating hormone.
  • Chlamydia test is a sexually transmitted infection STI that can affect infertility.

In select couples, the following additional tests may be warranted:

  • Pelvic ultrasound to assess for uterine myomas and ovarian cysts
  • Laparoscopy to identify endometriosis or other pelvic pathology

Assisted Reproductive Technology (ART):

  • The use of ART is dependent on each individual's or couple's situation and reason for infertility, patient's should seek the advise of a physician with a specialty in fertility for more information on this option

The success rate for surgical and medical approaches for infertility.

In- vitro fertilization IVF: 20.7%

Intrauterine insemination IUI: 4%

Gonadotropins alone: 7.7%

Gonadotropins with IUI: 17.1%

Without treatment: 1.3% to 3.8%

Resources[edit | edit source]

Podcasts by Natalie Crawford, MD

Assisted Reproductive Technology: An informative video on the process post egg retrieval

Article: Can Physiotherapists Play a Role in Fertility

Diet and fertility:

References[edit | edit source]

  1. Bakhtiyar K, Beiranvand R, Ardalan A, Changaee F, Almasian M, Badrizadeh A, Bastami F, Ebrahimzadeh F. An investigation of the effects of infertility on Women’s quality of life: a case-control study. BMC women's health. 2019 Dec;19(1):1-9.
  2. Wu AK, Elliott P, Katz PP, Smith JF. Time costs of fertility care: the hidden hardship of building a family. Fertility and sterility. 2013 Jun 1;99(7):2025-30.
  3. Hull MG, Glazener CM, Kelly NJ, Conway DI, Foster PA, Hinton RA, Coulson C, Lambert PA, Watt EM, Desai KM. Population study of causes, treatment, and outcome of infertility. Br Med J (Clin Res Ed). 1985 Dec 14;291(6510):1693-7.
  4. Medical Centric. Infertility, Causes, Signs and Symptoms, Diagnosis and Treatment. Available from: http://www.youtube.com/watch?v=UTZKFfEdv20[last accessed 19/9/2022]
  5. Hughes EG, Lamont DA, Beecroft ML, Wilson DM, Brennan BG, Rice SC. Randomized trial of a “stage-of-change” oriented smoking cessation intervention in infertile and pregnant women. Fertility and sterility. 2000 Sep 1;74(3):498-503.
  6. van der Steeg JW, Steures P, Eijkemans MJ, Habbema JD, Hompes PG, Burggraaff JM, Oosterhuis GJ, Bossuyt PM, van der Veen F, Mol BW. Obesity affects spontaneous pregnancy chances in subfertile, ovulatory women. Human reproduction. 2007 Dec 11;23(2):324-8.
  7. Gesink Law DC, Maclehose RF, Longnecker MP. Obesity and time to pregnancy. Human Reproduction. 2006 Nov 9;22(2):414-20.
  8. Ramlau-Hansen CH, Thulstrup AM, Nohr EA, Bonde JP, Sørensen TI, Olsen J. Subfecundity in overweight and obese couples. Human reproduction. 2007 Mar 7;22(6):1634-7.
  9. Nguyen RH, Wilcox AJ, Skjærven R, Baird DD. Men's body mass index and infertility. Human Reproduction. 2007 Jul 17;22(9):2488-93.
  10. Gaskins AJ, Rich-Edwards JW, Missmer SA, Rosner B, Chavarro JE. Association of fecundity with changes in adult female weight. Obstetrics and gynecology. 2015 Oct;126(4):850.
  11. Kiel IA, Lundgren KM, Mørkved S, Kjøtrød SB, Salvesen Ø, Romundstad LB, Moholdt T. Women undergoing assisted fertilisation and high-intensity interval training: a pilot randomised controlled trial. BMJ open sport & exercise medicine. 2018 Jul 1;4(1):e000387.
  12. Özcan Dağ Z, Dilbaz B. Impact of obesity on infertility in women. Journal of the Turkish-German Gynecological Association. 2015 Jun 1;16(2).
  13. Rittenberg V, Seshadri S, Sunkara SK, Sobaleva S, Oteng-Ntim E, El-Toukhy T. Effect of body mass index on IVF treatment outcome: an updated systematic review and meta-analysis. Reproductive biomedicine online. 2011 Oct 1;23(4):421-39.
  14. Wise LA, Rothman KJ, Mikkelsen EM, Sørensen HT, Riis AH, Hatch EE. A prospective cohort study of physical activity and time to pregnancy. Fertility and sterility. 2012 May 1;97(5):1136-42.
  15. 15.0 15.1 Abadia L, Chiu YH, Williams PL, Toth TL, Souter I, Hauser R, Chavarro JE, Gaskins AJ, EARTH Study Team. The association between pre-treatment maternal alcohol and caffeine intake and outcomes of assisted reproduction in a prospectively followed cohort. Human Reproduction. 2017 Aug 8;32(9):1846-54.
  16. Eggert J, Theobald H, Engfeldt P. Effects of alcohol consumption on female fertility during an 18-year period. Fertility and sterility. 2004 Feb 1;81(2):379-83.
  17. Matthiesen SM, Frederiksen Y, Ingerslev HJ, Zachariae R. Stress, distress and outcome of assisted reproductive technology (ART): a meta-analysis. Human reproduction. 2011 Aug 1;26(10):2763-76.
  18. Kiel IA, Lundgren KM, Mørkved S, Kjøtrød SB, Salvesen Ø, Romundstad LB, Moholdt T. Women undergoing assisted fertilisation and high-intensity interval training: a pilot randomised controlled trial. BMJ open sport & exercise medicine. 2018 Jul 1;4(1):e000387.
  19. Hakimi O, Cameron LC. Effect of exercise on ovulation: a systematic review. Sports Medicine. 2017 Aug 1;47(8):1555-67.
  20. Littman ED, Rydfors J, Milki AA. Exercise‐induced ovarian torsion in the cycle following gonadotrophin therapy: Case report. Human Reproduction. 2003 Aug 1;18(8):1641-2.
  21. Varras M, Tsikini A, Polyzos D, Samara CH, Hadjopoulos G, Akrivis CH. Uterine adnexal torsion: pathologic and gray-scale ultrasonographic findings. Clinical and experimental obstetrics & gynecology. 2004;31(1):34-8.
  22. Houry D, Abbott JT. Ovarian torsion: a fifteen-year review. Annals of emergency medicine. 2001 Aug 1;38(2):156-9.
  23. Wurn BF, Wurn LJ, King CR, Heuer MA, Roscow AS, Hornberger K, Scharf ES. Treating fallopian tube occlusion with a manual pelvic physical therapy. Alternative Therapies in Health & Medicine. 2008 Jan 1;14(1):18.
  24. Wurn BF, Wurn LJ, Roscow AS, King CR, Heuer MA, Scharf ES, Shuster JJ. Treating female infertility and improving IVF pregnancy rates with a manual physical therapy technique. Medscape General Medicine. 2004;6(2).  
  25. Kramp ME. Combined manual therapy techniques for the treatment of women with infertility: a case series. Journal of Osteopathic Medicine. 2012 Oct 1;112(10):680-4.
  26. Ruffini N, D’Alessandro G, Pimpinella A, Galli M, Galeotti T, Cerritelli F, Tramontano M. The Role of Osteopathic Care in Gynaecology and Obstetrics: An Updated Systematic Review. InHealthcare 2022 Aug (Vol. 10, No. 8, p. 1566). Multidisciplinary Digital Publishing Institute.
  27. Practice Committee of the American Society for Reproductive Medicine. Diagnostic evaluation of the infertile female: a committee opinion. Fertility and sterility. 2012 Aug 1;98(2):302-7.