Female infertility is a situation fraught with physical, mental, emotional, and even spiritual challenges. At some level, most humans experience the instinct to procreate, although obviously not all of us choose to follow that urge. In some cultures, even in a developed country like the United States, a woman’s sense of value and self-worth may be deeply and surprisingly connected to her ability to bear young.
A woman who does not conceive or successfully give birth to a longed-for child may go through periods when she questions her significance, her identity, her very reason for existence. If the chance for a sperm cell to encounter her ovum is somehow impaired, it isn’t a distant leap for a woman to feel responsible, even guilty, for that defect.
Infertility is defined in the United States as the inability to conceive a child after a full year of unprotected sexual intercourse. Infertility is not synonymous with sterility. Infertility is a condition in which it is difficult to conceive; sterility describes a situation where conception is impossible.
Statistics on infertility in the United States are difficult to gather, because not all affected people seek help. Some cases resolve spontaneously with a successful pregnancy; other couples give up. Some sources suggest that approximately 15 percent of couples are infertile and that physiological problems with the women in those couples are the obstacles to conception in about 70 percent of those cases.1 About 7 million women seek treatment for infertility each year.2
Recent developments in fertility assistance technology include hormone injections, in vitro fertilization, and other invasive techniques. They have improved the outlook for women who wish to carry a child, but even the most advanced interventions have a relatively low success rate, depending on the age and general health of the patient. Further invasive interventions carry many risks to both mothers and children.3
Alternatives to conventional fertility treatments exist, and couples seek them out increasingly in their quest for a healthy biological child. Massage therapists and bodywork practitioners are finding a place in this community of caregivers. This trust carries an astonishing level of responsibility.
Causes of Female Infertility
Causes of female infertility can be loosely grouped into four different categories: adhesion disorders, hormonal imbalances, structural anomalies, and environmental and behavioral factors. These are not always mutually exclusive.
Adhesion Disorders
Adhesion disorders include conditions and events that lead to the accumulation of excessive collagenous scar tissue in the pelvis. These adhesions can range from microscopic to obvious. They can interfere with fertility by limiting mobility of pelvic organs, creating pain with intercourse, impeding local blood and lymph flow, interrupting nerve function where neurons are bound up in fascial restrictions, and mechanically obstructing the surface of the ovaries and exterior and interior of the uterine tubes.4
Situations that can increase the risk of pelvic adhesions include:
Endometriosis. This common condition affects up to 5 million women in the United States. It is identified as a factor in about half of all infertile couples who seek help.5 Endometriosis involves the deposition of endometrial cells in areas outside the uterus: on the bladder, on the colon, or more problematically on the outside of the uterine tubes and/or ovaries. These deposits can stimulate an inflammatory reaction, leading to the creation of scar tissue cysts around them and the mechanical obstruction or strangulation of narrow openings.
Infection. Any history of pelvic infection or pelvic inflammatory disease (PID) can lead to scarring of the uterine tubes and a high risk of either infertility or ectopic pregnancy (a situation in which a fertilized egg implants in the uterine tube rather than in the uterus). The most common infectious agents in these situations are sexually transmitted bacteria. Chlamydia and gonorrhea infections are often silent or create only subtle symptoms, but the scar tissue they generate can interfere with fertility, even many years after the infection has subsided.6
Surgery. A woman with a history of abdominal or pelvic surgery is at risk for adhesions that may inappropriately link the fascial sheaths of internal organs, leading to poor mobility and interrupted blood, lymphatic, and nerve flow. Open surgeries carry a greater risk for postsurgical adhesions, but laparascopic surgeries can lead to restrictions as well.
Injury. Any kind of internal injury, from a ruptured cyst to a bad fall, can lead to the accumulation of scar tissue in the pelvis.
Hormonal Imbalances
Hormone disorders can impact fertility in ways we are still discovering; some of the links are indirect. Readers of Pathology Perspectives from Massage & Bodywork, January/February 2009 (“Polycystic Ovarian Syndrome and Metabolic Syndrome: A Hidden Link,” p. 110–115) may recall that some women with metabolic syndrome or pre-diabetes have had success improving their odds for successful pregnancy by altering their glucose-uptake activity. Improving insulin function seems to change how testosterone, estrogen, and progesterone promote ovarian function. Hormone disorders that contribute to female infertility include:
Hypothalamic disruption. The hypothalamus is a gland in the brain that controls endocrine system function by way of the pituitary gland. If the hypothalamus fails to stimulate the pituitary gland to release its cycle-inducing hormones, then ova never have the chance to mature and be released for possible fertilization.
Pituitary disruption. The pituitary gland, sometimes called the master gland because many of its secretions control other hormone glands, releases follicle stimulating hormone (FSH) and luteinizing hormone (LH), both of which control the ovaries to create the menstrual cycle. Pituitary tumors—both benign and malignant—can interfere with pituitary secretions.
Estrogen/progesterone imbalance. Having an imbalance in estrogen/progesterone secretions can alter the quality of the mucus in the female reproductive tract, making it more difficult for sperm cells to reach the ovum.
Polycystic ovarian syndrome (PCOS).
This is a condition in which the ovaries grow many cysts that interfere with ovulation and fertility. It is closely connected to other hormone disorders—metabolic syndrome and diabetes.
Structural Anomalies
Several structural problems can interfere with successful fertilization or the ability to carry a pregnancy to term. Part of a thorough screening must include checking for these factors:
Ovarian cysts. Ovarian cysts can take several forms, and they often overlap with hormonal problems. PCOS has already been discussed, but cysts can also occur singly. When this happens on the site of an egg that has not yet been released, it is called a follicular cyst. When it happens where an egg has already been released it is called a corpus luteum cyst. Either way, ovarian cysts can inhibit hormonal secretions from the ovaries, disrupting the menstrual cycle. A history of ovarian cysts can create excessive scarring, which can inhibit the release of a mature ovum.
Tubal dysfunction. A variety of problems can interfere with the function of uterine tubes. Scarring from previous infections and endometriosis are common, and a history of a “tubal” or ectopic pregnancy can all contribute to a non-functioning tube.
Fibroid tumors. Uterine fibroids or leiomyomas are benign tumors that occur in the muscular wall of the uterus, but they can also take the form of hanging growths that obstruct the uterine tube. Fibroids are common and often silent until a woman begins to investigate why she isn’t getting pregnant. Recent advances in surgical techniques allow for the removal of some fibroids while keeping the uterus intact for a chance at a successful pregnancy.
Environmental and Behavioral Factors
Fertility is potentially affected by many environmental factors. While each individual issue may be minor, a combination can have significant impact. Smoking, alcohol intake, and drug use can all impact the chances of a successful pregnancy. Exposure to environmental toxins, especially lead, some pesticides, radiation, and other substances, may lead to miscarriage and subsequent scarring. Extreme thinness, which can suppress ovulation, and being significantly overweight are also obstacles to fertility.
Perhaps the behavioral factor that is most frustrating to couples trying to conceive is the role that stress plays in this process. The link between stress hormones and reproductive hormones has not been extensively studied, but it is certainly anecdotally true that when some couples finally acknowledge that this event may never happen for them, they then find themselves unexpectedly (and joyfully) pregnant.
Bodywork Interventions
Massage and bodywork modalities from all over the world have an ancient tradition of working to promote healthy female fertility. Recently, some protocols addressing the pelvic environment have been developed. Some combine massage and aspects of physical therapy, and small-scale studies show some success in increasing both tubal patency (the ability for sperm cells to travel through the uterine tube) and pregnancy rates.7
According to Marty Ryan, a massage therapist who specializes in addressing abdominal and pelvic issues, the exact mechanism for how these techniques work isn’t clear. In his words, “Externally manipulating, stretching, and creating slack in the fallopian tubes is not so difficult if you can find the appropriate landmarks. Improving the general connective tissue quality in terms of arterial blood, venous and lymph return, mobility, elasticity, and overall slide and glide is of course a great thing.”8
The benefits of using bodywork as an intervention to improve fertility seem self-evident: this approach doesn’t involve knives, needles, lasers, or chemicals; it is physically and emotionally supportive during a time of great stress; and it harnesses the natural processes of the body to create an avenue for a happy outcome. However, it is important to point out that pelvic massage for a client who struggles with fertility is not a risk-free undertaking. Without adequate education and information, a therapist could be dabbling in an environment that is poorly understood. Risks include rupturing a cyst, working around unresolved abscesses, manipulating a fibroid tumor, or in a worst-case scenario, working with undiagnosed ovarian cancer that is spread most efficiently through peritoneal fluid.9 These possibilities must all be addressed when working with a client who might benefit from deep-pelvic massage, which is why working as part of a healthcare team and getting a thorough health history are absolutely critical in this setting.
In Conclusion
I must confess to entering into my exploration of the use of deep pelvic massage for infertility with a certain level of skepticism. Because my interest is in pathophysiology, I tend to look at situations from that perspective, and I was concerned about people making overstated claims about what massage can do in a situation where a client has every reason to cling to every hint of a hopeful conclusion. Further, I worry about ill-prepared therapists making mistakes and causing physical harm. I have been on the scene when a student learning psoas work ruptured an ovarian cyst in her partner, leading to a trip to the emergency room. But as I learned more about how well-trained therapists can differentiate between healthy and unhealthy tissue, and began to understand some ideas about how fascial restrictions can cause problems, and how manipulation can ease them, I have become convinced that this is a field that holds enormous promise and potential for our clients who struggle with this issue.
Ruth Werner is a writer and educator who teaches several courses at the Myotherapy College of Utah and is approved by the NCBTMB as a provider of continuing education. She wrote A Massage Therapist’s Guide to Pathology (Lippincott Williams & Wilkins, 2009), now in its fourth edition, which is used in massage schools worldwide. Werner is available at www.ruthwerner.com or wernerworkshops@ruthwerner.com.
notes
1. What Causes Female Infertility? Stanford University, 2009. Available at www.stanford.edu/class/siw198q/websites/reprotech/New%20Ways%20of%20Making%20Babies/Causefem.htm (accessed August 2009).
2. M. P. McCarthy, RN, CNS, PhD, “Women’s Lived Experience of Infertility After Medical Intervention,” Journal of Midwifery & Women’s Health 53, no. 4 (2008): 319–24. Available at www.medscape.com/viewarticle/577014 (accessed August 2009).
3. Shirley Vanderbilt, “Soft Tissue Massage: Infertility Treatment of the New Millennium?” Massage & Bodywork 14, no. 6 (2000): 56–8. Available at www.massagetherapy.com/articles/index.php/article_id/282 (accessed August 2009).
4. Although they have traditionally been called fallopiantubes after the 16th-century anatomist Gabriele Fallopio, a movement toward substituting functional names for personal names has led to the use of uterine tube or oviduct for these structures.
5. P. Kovacs, MD, PhD, “Endometriosis and Primary Infertility,” Medscape Ob/Gyn & Women’s Health 10, no. 2 (2005). Available at www.medscape.com/viewarticle/511725 (accessed August 2009).
6. What Causes Female Infertility?
7. Belinda F. Wurn, PT et al., “Treating Female Infertility and Improving IVF Pregnancy Rates With a Manual Physical Therapy Technique,” Medscape General Medicine 6, no. 2 (2004): 51. Available at www.medscape.com/viewarticle/480429 (accessed August 2009).
8. Marty Ryan, e-mail correspondence (July 2009).
9. Ruth Werner, A Massage Therapist’s Guide to Pathology, fourth edition (Lippincott Williams & Wilkins, 20