Exploring how manual therapy can assist female infertility patients
By Danisha Christian, LMP March 2015
Manual therapy for fertility enhancement is an effective treatment that should be incorporated into treatment plans for patients having a difficult time trying to conceive naturally and/or with the help of Assisted Reproductive Technologies (ART). For women struggling to get pregnant, there is often a sense of desperation that will cause them to try anything that promises to increase their chances of success. Doctors who do not want to exploit this desperation may be appropriately reluctant to suggest alternative treatments or complimentary medicine to assist with conception. In addition, many allopathic doctors, including Reproductive Endocrinologists, have limited knowledge of these treatment modalities. There is also little research funded for alternative and complementary medical treatments. Due to lack of research, the modality lacks credibility in scientific arenas. Through my extensive background and experience in the field of manual therapy for fertility enhancement, I can say conclusively that manual therapy is an effective form of treatment for women struggling to conceive.
Since 2003, I have studied the physiological and biomechanical aspects of conception and female reproductive conditions. I went to massage school in order to begin working with patients trying to conceive. I completed a year-long, 1,000 hour program at the Brenneke School of Massage where I studied anatomy, physiology, kinesiology and massage techniques. I apprenticed with renowned Naprapath Dr. Rosita Arvigo, D.N. in Belize, and a number of indigenous women in Belize and the U.S. who have passed down centuries-old methods of massage/manual therapy to help women with reproductive conditions conceive. I began seeing fertility patients in 2006. Since then, I have assisted approximately 80% of my patients with an infertility diagnosis conceive by using external manual therapy techniques to improve their fertility. By highlighting examples from my personal case studies and exploring scientific data done on manual therapy and massage, we will consider how manual therapy impacts fertility outcomes.
According to the Center for Disease Control, infertility is a disease affecting 11% of women and is characterized by the inability to get pregnant or stay pregnant. Most women trying to conceive on their own for over a year without success, have an infertility diagnosis. It often takes the intervention of fertility specialists to diagnose the root of the problem. The Association for Reproductive Medicine (ASRM) approximates that in about 20% of couples with an infertility diagnosis, the underlining cause is unknown. In other instances, some commonly seen reasons for female infertility include poor egg quality, thin uterine lining and pelvic adhesions. According to ASRM, 85-90% of infertility cases, can be treated with either drug therapy or a surgical procedure. Only about 3% of cases require advanced interventions such as in vitro fertilization (IVF). In some cases, women are not responsive to the drug therapies, creating an additional challenge for doctors and patients alike. Because drug therapy is so often successful in treating infertility, for the women who do not respond, it becomes another barrier to conception. I will characterize this cause as poor response to drug therapies. Manual therapy and massage can impact the above stated conditions.
Massage therapy is the scientific manipulation of the soft tissues of the body. My techniques for manual therapy for fertility enhancement incorporate several well-known modalities of bodywork, including: Maya Abdominal Massage, structural integration, myofascial release, trigger point therapy, applied physiology, deep tissue, patient- assisted movements, neuromuscular education, passive stretching, hydrotherapy, isometric muscle balancing, manual lymph drainage, naprapathy, reflexology, and visceral manipulation. Combined based on the needs of the patient, they are effective tools to address the needs of women trying to conceive.
Critics have raised questions around the legitimacy of mechanical manipulations assisting with fertility enhancement instead citing the benefits of massage on stress reduction. While it is true that massage reduces stress, and has been shown in studies to therefore decrease cortisol levels, increase oxitocin levels and lower blood pressure (Rapaport, Schettler and Bresee), there are mechanical benefits as well. It is also difficult for some to imagine that manual therapy could improve rates with scientific significance when we are dealing with complex endocrine cases. A survey of physicians in 1995 showed that 70 of the 90 physicians polled, thought alternative medicine to be a legitimate form of medicine. However, the modalities in which the physicians had the least amount of training, were considered the least legitimate where the modalities they had the most familiarity, they considered the more legitimate (Berman). Funding for studies would certainly help de-mystify the practice. For our purposes here, we will consider the potential impact manual therapy could have on particular conditions by using deductive reasoning.
Massage has been proven to have a significant impact on the circulatory system by increasing the flow of blood and lymph. Scientists have started to explore the role of circulation in fertility. In the study, “Pathophysiologic Feature of Thin Endometrium”, published in Fertility and Sterility, doctors consider the role of blood flow to the endometrium via the radial artery, in building a sufficient uterine lining. The study indicates that blood flow impedance can play a role in underdeveloped linings. The study concluded that a “thin endometrium (less than 8 mm) was characterized by high blood flow impedance of RA, poor epithelial growth, decreased VEGF expression, and poor vascular development” (Miwa, et al.). In an earlier study, also published in Fertility and Sterility, doctors considered if increased blood flow through the uterine radial artery impacted the thickness and quality of the endometrial lining. The study used vitamin supplements and/or drugs to increase circulation in this artery (vitamin E, L-arginine, or slidenafil). It was found that increasing vascularity in the uterine radial artery did increase the uterine lining in study subjects (Takasaki, et al.). Since we know that massage therapy can significantly increase blood flow, we should consider the impact that strategic, deliberate work to increase circulation through the uterine radial artery could have on building a quality endometrial lining. Through my own practice, I have seen significant improvement to a woman’s uterine lining after receiving manual therapy treatments.
Ovarian function, which impacts the quantity and quality of eggs produced, could also benefit from enhanced blood flow through the ovarian artery; an artery with its origin in the aorta, and distribution to the ureter, ovary, ovarian ligament, uterine tube. In my own practice, I have seen a number of patients with repeated IVF attempts, where they struggled to produce sufficient size and quantity of eggs. After receiving a series of treatments and performing a self massage that I taught them, they have been able to document an increase in the amount of and size of their eggs. It is also remarkable that in my estimation, about 95% of the time, the ovary that performs best, is the one with the least amount congestion around it. I can almost always estimate which ovary will perform better by simply palpating the low abdomen and groin, and asking some basic health history questions. By performing manual therapy for fertility enhancement, we reduce the congestion in the pelvis, almost always leading to improved ovarian function, egg quality and quantity.
Circulation is essential to the efficacy of drug treatments. Hormones and drugs are carried to their respective receptor sites by the blood. It is critical for hormones and drugs to reach the ovaries, pituitary gland and endocrine receptor sites, in order for them to be effective. Often times, it is a mystery as to why a woman will not respond to fertility drugs. Doctors may try drug after drug looking for one that would work for a patient. However, there are some women who simply do not respond. For these women, manual therapy can help break up scar tissue around endocrine glands, possibly stimulate endocrine glands and increase circulation. I have worked with patients who have had both minor and drastic changes in their response to fertility drugs after receiving a series of treatments.
In a 2004 study, it was revealed that manual therapy can be useful for breaking up scar tissue and pelvic adhesions. Practitioners used internal manual therapy techniques to help increase fertility (Wurn, et al.). It is necessary to point out that I have also seen a great deal of success in breaking up pelvic scar tissue and adhesions from external manual therapy techniques in my own practice. Manual therapy and massage are known to be able to successfully break up scar tissue, realign fibers and release fascia that is improperly bound. For my fertility patients, we spend a great deal of time addressing old injuries, endometriosis and scaring from surgery sites. Scar tissue can play a considerable role in a woman’s inability to conceive. Often times this comes in the form of endometriosis, but it can also be from previous falls, motor vehicle accidents and abdominal or vaginal surgeries.
Finally, we should consider the nervous system’s role in conception. A study published in 2013 suggests that the Vagus nerve plays an integral role in ovulation. The study states: “in EV-induced PCOS rats the Vagus nerve is a neural pathway participating in maintaining PCOS. The Vagus nerve innervates the ovaries directly and indirectly through its synapsis in the celiac-superior-mesenteric ganglion, where the somas of neurons originating in the SON are located. Then, it is possible that vagotomy effects in EV-induced PCOS rats may be explained as a lack of communication between the central nervous system and the ovaries” (Linares, et al.). Massage and manual therapy are known to help alleviate peripheral neurological conditions such as neuromuscular nerve impingements. Part of my technique includes searching for and addressing adhesions, scar tissue or muscular hypertonicty that may be interfering with the peripherial nervous system. These peripheral nerve impingements might account for some cases of “unexplained infertility.” I have seen patients with a significant number of adhesions on and around their low back and sacrum experience success after years of unsuccessful attempts.
Scientists should have a healthy inquisitive interest in pursuing studies that explore the efficacy of this treatment modality. Manual therapy is a safe, effective therapy that compliments all other fertility interventions. Funding should be made available for further investigation. In the meantime, doctors should consider referring their patients to manual therapists that specialize in fertility enhancement to increase their patient’s chances of success.
American Society for Reproductive Medicine. American Society for Reproductive Medicine. ASRM, n.d. Web. March 2015.
The American Heritage Medical Dictionary, Houghton Mifflin Company, 2007, 2004. s.v. uterine radial artery
Berman, Singh, Lao, Singh, Ferentz, Hartnoll, “ Physicians’ attitudes toward complementary or alternative medicine: a regional survey,” The Journal of the American Board of Family Practice/American Board of Family Practice, October 1995. PMID: 7484223
Center for Disease Control. Center for Disease Control. CDC, 2013. Web. March 2015.
Rapaport, Mark Hyman MD, Schettler, Pamela PhD, and Bresee, Catherine MS, “A Preliminary Study of the Effects of a Single Session of Swedish Massage on Hypothalamic–Pituitary–Adrenal and Immune Function in Normal Individuals,” Journal of Alternative and Complimentary Medicine, October 2010. doi: 10.1089/acm.2009.0634
Linares, Rosa, Hernández, Denisse, Morán, Carolina, Chavira, Roberto “Unilateral or bilateral vagotomy induces ovulation in both ovaries of rats with polycystic ovarian syndrome” July 2013. doi: 10.1186/1477-7827-11-68
Miwa, Ichiro M.D., Tamura, Hiroshi M.D., Ph.D., Takasaki, Akihisa M.D., Ph.D., Yamagata, Yoshiaki M.D., Ph.D., Shimamura, Katsunori M.D., Ph.D., and Sugino, Norihiro M.D., Ph.D. “Pathophysiologic features of ‘‘thin’’ endometrium” Fertility and Sterility, 2009. 91:998–1004. 2009
Takasaki, Tamura, Miwa, Taketani, Shimamura, Sugino, “Endometrial growth and uterine blood flow: a pilot study for improving endometrial thickness in the patients with a thin endometrium,” Fertility and Sterility, April 2010. doi: 10.1016/j.fertnstert.2008.12.062.
Wurn, Belinda PT, Wurn, Lawrence LMT, King, Richard MD, Heuer, Marvin A. MD, Roscow, Amanda MPT, Scharf, Eugenia PhD, Shuster, Jonathan PhD, “Treating Female Infertility and Improving IVF Pregnancy Rates With a Manual Physical Therapy Technique,” Medscape General Medicine. June 2004. PMC1395760