Infertility 2/12/2005
by Marco Lam, L.Ac.
We are all so busy. We sometimes put off the most important things in life to just deal with those that are most urgent. For many woman and families, one of the most important passages of life is getting pregnant and entering motherhood. A woman is born with over three hundred thousand eggs inside of her ovaries, but the fertility of those eggs deteriorates with age, environmental pollutants, pharmaceutical medications, poor diet and stress. Fertility is a such a subtle barometer of our health, many couples consider themselves perfectly healthy until they experience problems with conception or pregnancy. A woman who has waited until later in her reproductive life to become pregnant may find that she is unable to do so because the viability of the eggs or sperm have become compromised. The shock, disbelief and sadness that a couple feels can be overwhelming when they discover that no matter how young they look or feel, they can no longer conceive.
According to Dr. Worley at the Conceptions Reproductive Associates in Boulder, “Infertility is a growing issue. Infertility now affects over 6 million American women and their partners, roughly 10 percent of the reproductive age population. Women are waiting until later in their lives to have children, whether due to career, marrying older or delaying pregnancy for financial reasons. Most women are not aware of how rapidly their fertility declines after their early 30’s.” Many patients come to the comfortable and friendly presence of the grandfatherly Dr. Worley seeking the use of assisted reproductive technologies (ART) in the belief that you delay pregnancy and use ART when you are ready. However, according to the American Society for Reproductive Medicine’s website, age affects the success rates of both infertility treatments as well as your natural ability to get pregnant. For example, if a healthy 30 year old woman has a 20% chance per month of getting pregnant, by the time you are 40 the chance is down to 5%. Infertility is defined as not being able to get pregnant after a year of unprotected intercourse. Male and female factors each account for roughly a third of infertility problems. The remaining third are either a combination of male or female factors or are unexplained.
“The problem of infertility is strictly a matter of reproductive biology. The reason they’re not pregnant is one of five things: one; the egg is not entering the fallopian tubes. Two; the sperm is not getting there. Three; the sperm and egg are together but the sperm is not penetrating the egg. Four; the egg is penetrated but doesn’t begin cell division. Five; the egg is fertilized but either doesn’t implant into the uterus or begins to degenerate,” says Dr. Worley finishing with some compassionate advice, “It is important to focus on the necessity that the answer is one of those five, so that the couple doesn’t doubt their appropriateness of becoming parents or that the ability to conceive a child is some sort of moral reward. Kids are conceived all over the world under all kinds of conditions, both good and bad, moral and immoral. For a couple to project their difficulty in having a child as some sort reflection of their unworthiness – it is not true and these couples struggling with infertility are all too good at doing exactly that.”
The Ten Thousand Dollar Chance
Most ART procedures begin with medications that manipulate the body’s production of reproductive hormones to encourage the development of multiple follicles (sacs inside the ovary that contain the egg released at ovulation) and to control the timing of the reproductive cycle. From there, the options in fertility treatment get very complicated and the number of choices and different techniques can be overwhelming. Everywhere from Intracytoplasmic Sperm Injection (injecting weak sperm into an egg) to space-age sounding technologies such as Blastocyst transfer (transplanting of embryos) and cryopreservation of eggs and embryos, the options can overwhelm the patient. The different techniques to treat infertility hinge on which of these problems is causing the infertility and the amount of invasiveness a patient is willing to undergo. The best known of these techniques is IVF (In Vitro Fertilization), but is very expensive and rarely covered by insurance. According to the American Society for Reproductive Medicine (ASRM) website, the average cost of an IVF procedure is over $12,400. The first successful IVF was used in the US in 1981 and since then over 100,000 babies have been born using that technique. During an IVF cycle, an egg and sperm are collected and placed in a laboratory dish to fertilize. If the eggs are successfully fertilized, they are transplanted into a woman’s uterus. According to ASRM’s website, “Women under 35, without a male factor in the infertility, who try IVF, have on average a 25% chance of conceiving and having a baby. Of the 82% of pregnancies as a result of IVF that result in a live birth, about 63% are singletons, 32% are twins, and 5% are triplets or more.” The factors of high cost of the procedure and the clinics which want to have a high published rate of success (to attract more patients), encourage the implantation of multiple embryos to ensure a higher rate of success. Spending over $10,000 with a 25% chance of success, takes the prospective parents on a roller coaster ride of emotions akin to a high stakes gamble with a life involved. Even more expensive options exist when the egg used in IVF does not come from the prospective parent but comes from a young woman donor who undergoes the ovulation induction and egg retrieval for the recipient.
Even if not pursuing a fairly complicated treatment like IVF, the invasiveness of the procedures and emotional toll can be incredible. Yet, the desire for children seems to overweigh the challenges associated with the procedures for many women. Sarah Clarke Kleinhans, a local mother of one who is expecting another, bravely put forth, “Though I wasn’t classified as infertile, I needed to use ART because my body’s tendency to miscarriage. I put my career as a dancer and model first and thought it would be easy to get pregnant later. We planned a pregnancy because we knew we wanted children. I am incredibly grateful to be a mother now, but it was an emotional roller coaster. Every month that you get a negative pregnancy test it is devastating. People who say ‘I got pregnant the first time’ are really hard on how you feel about yourself. I was so angry at my body and wanted a baby so bad.” The bravery and tenaciousness of the women who go through ART procedures seems like that of those who survive major illnesses. Clarke Kleinhans relates, “Because of a clotting disorder my body has, at one time in my pregnancy I had to take 16 injections a week of progesterone and heparin to keep my baby. I have almost lost my baby 4 times and at one time in my 2nd pregnancy, I had signs of impending miscarriage and was hospitalized. Now, I just cross my fingers.”
Natural Ways of fertility
There are many advocates of more natural methods of trying to increase fertility. The general alternative medicine approach differs from the allopathic approach in that it takes a holistic approach to medical treatment, treating all causes of a problem rather than just symptoms that accompany the problem. A holistic medical practitioner sees an individual as an integrated mind and body organism, rather than an individual with a pathology to remove. In traditions such as Chinese medicine, Naturopathy and Ayurveda, the emotional experiences, diet, work habits, work and living environment, personal habits and the social milieu are factors that contribute to disease and are factors which, when adapted appropriately may lead to regained health. Perhaps, the strongest link between most alternative approaches is nutrition which most modalities agree is crucial to health.
Dr. Mark Bush, a dual board-certified doctor in Obstetric/Gynecology and Reproductive/Endocrine/Infertility is coming out to join Dr. Worley in Boulder in May and he supports integrating more complementary practices into treating patients with infertility. Dr. Bush is a representative of the next generation of doctors who believe in a more open-minded approach to holistic health care and believes that the MD’s who do not observe the cultural shift toward integrating complementary modalities will be left behind by their patients. Dr. Bush says, “It makes sense to first try to balance the mind-body connection with nutrition and lifestyle changes to reduce stress. By using natural methods, a patient can enter the ‘infertility staircase’ as a lower level and use less invasive methods. There are numerous studies that show the importance of zinc and folic acid in prenatal nutrition and the health of the reproductive organs. I encourage organic whole foods and omega-3 oils for my patients. Chemical residues in foods have been shown to impact reproductive function and I heartily recommend eating organic food to my patients.” One aspect of nutrition that particularly relates to infertility is that the modern western body image is not necessarily the one that is most conducive to getting pregnant. According to Dr. Bush, “From animal studies we know that pregnancy usually occurs in a anabolic state, when the body is growing and putting on weight. The obsession with being thin can stop the body from retaining the fat reserves associated with the optimal hormonal profiles of getting pregnant. There is a sense of relief in some of my patients when they have the permission to put on some weight.” The nutritional information on the internet is quite extensive, with numerous websites such as healingwithnutrition.com advocating that knowledge of nutrition gives a person many options for managing infertility and they can then personally take charge of the effect this condition is having on their life. Though not all may agree with nutrition as a strong factor, Dr Worley says, “There is not a lot of data that suggests that alterations in diet strongly effects fertility. Numerous studies champion a vitamin or supplement, but most of the studies are done by those selling the product and the data tends to be soft and the trials poorly done.”
Stress is another possible road block to successful conception, especially when the couple is extremely anxious about their fertility and worried about not being able to have a baby. As Dr. Worley explained there are 5 possible reasons for infertility, all of which were biological but as recently as the late 1960s, it was commonly diagnosed that reproductive failure was the result of psychological and emotional factors. “Infertility was supposed to occur because of unconscious anxiety about sexual feelings, ambivalence toward motherhood, unresolved oedipal conflict, or conflicts of gender identity. Fortunately, advances in reproductive endocrinology and medical technology as well as in psychological research have de-emphasized the significance of psychopathology as the basis of infertility, and modern research shows that there is little evidence to support a role for personality factors or conflicts as a cause of infertility. This perspective unburdens the couple by relieving them of the additional guilt of thinking that it is their mental stress that may be responsible for their infertility,” wrote Dr. Mike Berkley, in TCM and Infertility.
Yet, stress is still shown to be a contributing factor as biologically the hypothalamus regulates both stress responses as well as the sex hormones. According to Dr. Bush, “In a stressful environment, the body releases corticotrophin releasing hormones (CRH) which through the pituitary and adrenal glands, ramps down gonadal function and inhibits secretion of gonadtropins which control ovulation. The hormones secreted by a stressed system can interfere with the transport of gametes through the Fallopian tube or by altering uterine blood flow. This is a critical piece in treating infertility that is overlooked but relatively easily treated by positive lifestyle change such as adequate sleep and relaxation exercises.” Western medicine has many possible models for the cascade of effects from different hormones, but in reality the mechanism of interaction is so complex that researchers are far from understanding how stress interacts with the reproductive anatomy. Modern medicine is beginning to embrace the far edge of medical science in pyschneuroimmunology, which is making serious attempts into apply science to the connection between mind and body. Much of the research focuses on the molecules which the brain produces in response to emotions. These molecules, known as neuropeptides, interact with system in the body, including the immune system and reproduction. In the far edge of modern research, western medical practice is running into the major premise of all older medical systems, the basic truth that mind and body are not only connected but inseparable.
A Needle in the Haystack
Another method on the path to natural healing is using acupuncture to increase fertility. Many viewers of the popular ‘Sex in the City’ sitcom were exposed to fertility acupuncture when one of its characters conceived after receiving acupuncture. Sitcoms aside, there is now a strong clinical research study from Germany that showed how a specific acupuncture treatment could raise the success rate of in patients undergoing ART from 26.3% to 42.5% (ref: Medline 11937123). Acupuncture is one of the few alternative modalities that his been tested under randomized control trial with infertility patients in a clinical setting. Even the skeptical Dr. Worley recommends acupuncture in patients undergoing IVF, though with this caveat, “I must tell you this is not out of deep conviction that acupuncture markedly improves chances at pregnancy but out of recognition that acupuncture has been shown to increase reproductive blood flow when properly applied. This is a change that has been objectively verified by ultrasound and it is widely assumed that increased reproductive blood flow increases the likelihood of pregnancy.” Dr. Bush is more enthusiastic about the results, saying, “The data was solid and bias was eliminated with randomized controls. It is a treatment that has little to know side effects and is very well received and even enjoyed by patients. Acupuncture is not really alternative medicine, it is traditional medicine. Chinese medicine has been around for thousands of years and western medicine is just beginning to see the possibilities.” Modern researchers agree that acupuncture releases endorphins which mitigate ones response to stressful stimuli. This adaptation to stress may be one of the reasons that acupuncture enhancing the possibility for conception in addition to those found in this study.
In the end, it is obvious on a gut level that the better your level of health is, the better your fertility is. It seems like basic biology. It makes sense to optimize your personal levels of wellness through diet, exercise, attitude and support. There is growing evidence to support complementary medicine, especially acupuncture, in the treatment of infertility and in aiding the success rates of Western medicine’s methods of IVF. There exist groups which are against using technology to conceive a child and view it as tampering with nature, and that if the parents were destined to have a child, they would have. Yet, the courage the women need to go through the invasive procedures of ART comes from a craving for motherhood that comes from a place that is powerfully rooted in our very human nature to survive and procreate.