Throughout history, infertility has had implications in society with effects that reach into the medical, social, emotional, political, and religious arenas. The approach to treating infertility is unique because it involves assessing and addressing the couple, as opposed to an individual. Treatment and care vary widely as each couple has a unique story.
Infertility can be associated with many other conditions such as:
Autoimmune disease
Diabetes
Hyperthyroid
Hypothyroid
Chronic Stress
Chronic sleep disturbances
Obesity
Anorexia
Endocrine dysfunction
Alcohol and smoking consumption
Environmental pollutants and toxicity
Polycystic Ovarian Syndrome
Irregular menstrual cycles
Endometriosis
Uterine Fibroids
Uterine Polyps
Uterine Leiomyoma
Decreased libido
Difficulty with erections
Past genital infections
What Is Infertility?
Currently, infertility is defined as the inability to carry a pregnancy to full term within a period of 12 months for a woman less than 35 years old, and the inability to carry to full term within 6 months for a woman 35 years and older.1 Age of the couple has a strong relationship to the health of the egg, hormone production, and sperm quality and quantity. A woman’s peak fertility time is in her late teens to early twenties and declines after the age of 30-35. For men, sperm count drops with age and sometimes along with sexual function.4
What Causes Infertility?
Multiple studies have documented female, male, and factors of both partners as causes of infertility. Infertility can be caused by a structural abnormality of the uterus, vagina, or testes. It can be caused by a production or transportation issue to the egg or sperm. It is implicated with sexual dysfunction, stress, environmental toxicity, chronic inflammation, and dysfunction of the endocrine system.2,3 A population-based study found a correlation of infertility to be 26% due to a male factor, 21% due to an ovulatory dysfunction, 14% due to fallopian tubal damage, 6% due to endometriosis, 6% due to coital problems, 3% due to a cervical factor, and 28% with an unexplained cause. 1
What is associated with the male factors?
It is found that 30-40% of cases of male infertility are due to problems with the testes, 10-12% are due to blockage in the transportation of the sperm during ejaculation, 1-2% are due to dysfunction of the pituitary gland or hypothalamus (glands that balance the endocrine system and hormones), and 40-50% with an unknown cause.4 Problems with the sperm can be related to the amount, the shape, and their ability to move in a straight line. As with the women, genetic disorders, hormonal imbalances, systemic illnesses, local trauma, and environmental factors are implicated with the men. Hormonal imbalances and impaired sperm production can arise from acute and chronic illnesses such as anemia, rheumatoid arthritis, thyroid disease, Cushing’s syndrome, obesity, trauma, burns, and liver dysfunction.5 Connective tissue disorders, aging, inflammation, and infection increase oxidation within the body. This oxidative stress may have additive effects with the locally produced oxidation within the testes and work together to decrease a fertile environment for the sperm. 5,8
There is also growing concern of how environmental toxins and influences are acting synergistically with genetic predisposition to alter testicular development. This concept is referred to as testicular dysgenesis syndrome. It encompasses how the environment, diet, and lifestyle factors affect male endocrine disruption, resulting in increased incidences of cryptorchidism (undescended testes), hypospadias (a congenital defect resulting in the urethra opening that develops on the underside of the penis), testicular cancer, and defects of the sperm.5, 6, 7 The environmental factors include xenoestrogens, pesticides, and solvents.6
What is associated with the female factors?
The first step in becoming pregnant requires ovulation. This step accounts for 21% of infertility. 1 Ovulation is when an ovary releases one egg for fertilization by sperm. In a healthy woman, ovulation occurs mid cycle when her luteinizing hormone (LH) peak stimulates the release of the egg and production of progesterone. It is the progesterone that will sustain the fetal development during the pregnancy. In order for her body to produce the LH surge, she has to have a healthy endocrine system that releases the appropriate signals for the ovaries to produce the hormones and eggs. Sometimes, the hormonal signals are insufficient and the ovaries cannot respond to the hormonal signals either due to damage, or antibodies and allergies that clog the hormone receptors.
The next step is when the egg travels down the fallopian tube. This step accounts for 14% of infertility. 1 The tubes have fine hair-like projections called cilia that move like a wave to move the egg down the tubes. Just after ovulation, the cilia wave motion increases to assist movement of the egg. This increase in movement is depending on hormone production from the ovaries. Factors that are involved with either slowing down the wave-like beat, covering the cilia, or causing scarring include smoking, bacterial infections, and endometriosis.9
The next step is when the egg becomes fertilized by the sperm. In order for the sperm to reach the egg, the cervix produces mucus that creates a friendly environmental pH and creates channels to guide the sperm. In this alkaline environment created by the mucus, the sperm can live up to four days. Any type of infection or cervical procedure that damages the mucus glands will make it more difficult for the sperm to reach the egg. The women’s body also sometimes created antibodies to the sperm that inhibit fertilization. 10
Once the egg is fertilized, it has to implant into the lining of the uterus. Polyps and fibroids can prevent this implantation. If the egg does implant, the ovaries will begin to take over progesterone production to sustain the fetus. If the ovaries are dysfunctional, a miscarriage will result due to low progesterone levels.
What tests are typically done?
For both men and women, testing may be done that assesses the endocrine health. The endocrine system is involved in your hormone production and regulation. It includes your testes, ovaries, adrenal glands, thyroid gland, and hypothalamus. This commonly includes follicle stimulating hormone (FSH), luteinizing hormone, estrogen, progesterone, testosterone, and thyroid analysis. For men, a semen analysis is typically performed. This looks for the quantity, quality, and morphology of the semen. For women, imaging may also be performed to look at anatomical aspects of the uterus and ovaries.
How is infertility treated conventionally?
Because there are a wide variety of causes for both male and female infertility, the treatments are vast and vary depending on each case from medications for hormone regulation to surgery and assisted reproductive technology. Medications may be prescribed to induce ovulation, to stimulate FSH or LH to balance the hormone production, and to decrease insulin resistance in patients with Polycystic Ovarian Syndrome. The most common medication used to induce ovulation include Clomiphene citrate. Clomiphene citrate competes with estrogen for estrogen receptors and will either stimulate or inhibit estrogen receptor activity depending on the tissue. It effects the hypothalamus, pituitary, ovary, and uterus. Ovarian stimulation will be used along with assisted reproductive procedures to increase the chance of conceiving. Side effects include ovarian enlargement, hot flashes, blurred vision, double vision, headaches, mood swings, depression, nausea, vomiting, and rarely ovarian hyperstimulation syndrome which will be discussed later in the article.
What about assisted Reproductive Technology?
Assisted reproductive technology usually is reserved for couples who have been unable to become pregnant with other treatments. Assisted reproductive technology includes intracervical insemination, intrauterine insemination, invitro fertilization, and intracytoplasmic sperm injection. Intracervical insemination (ICI), is the process by which fresh sperm are inserted into the vagina near the opening of the cervix. This method is not as common and requires that there are no other problems with the sperm’s shape and movement, problems that would interfere with the fertilization of the egg, or problems with the female’s ability to carry the pregnancy. With couples seeking fertility assistance, ICI has been shown to not be as effective when compared to Intrauterine insemination (IUI).11 Intrauterine insemination is the process where sperm are concentrated and placed directly into the uterus. This increases the sperm concentration that reaches the egg. IUI is sometimes performed with medications that induce ovulation to increase the chance for pregnancy.12 Some types of infertility that it is used with include ejaculatory dysfunction, impotence, endometriosis, cervical factor infertility, and male factor infertility.13 It is commonly used as an intermediate level procedure that is more cost-effective than the in vitro fertilization. Invitro fertilization (IVF), is the process where eggs taken from the women are surrounded by sperm. Once the eggs become fertilized, they are re-implanted into the uterus. IVF is reserved for couples who have severe male factor infertility, where both fallopian tubes in the woman are closed from scarring or other causes, and where couples have been unable to conceive with other assisted reproductive technologies. IVF is a reserved treatment because it is a costly procedure; there is a risk of multiple embryos developing at the same time, and an increased risk in fetal complications. There is evidence showing that some pregnancies resulting from IVF or intracytoplasmic sperm injection result in pre-mature bith, low bith weight, and higher risks of chromosomal and musculoskeletal birth defects than infants conceived naturally.14, 15 Women who receive IVF commonly have fertility issues that require medications to help sustain the pregnancy. For couples where male infertility is a strong component, intracytoplasmic sperm injection (ICSI) therapy is sometimes used. ICSI is the process where mature eggs are directly injected with one sperm. Because the sperm are manually inserted into the eggs, it is used where there are less than 2 million motile sperm, there is limited quality and quantity of frozen sperm, there is obstruction within the male reproductive tract that cannot be surgically repaired, there is abnormal shape in greater than 95% of the sperm, antisperm antibodies are present, and there is failure with previous IVF protocols.16 ICSI has similar risks as IVF as discussed previously. These risks may be resulting from the procedure itself as there may be injection of contaminants, the injection may disrupt the environment that the egg sits in, and it may disrupt the normal genetic process of egg development.17
What are the risks with artificial reproductive technology?
For men, the main risks include bleeding, infection, and damage to the testes after procedures that retrieve sperm for fertilization of the eggs.
For women, the main risks include infection, damage to the blood vessels, and damage to reproductive and surrounding organs. Ovarian hyperstimulation syndrome, while rare with IVF, is a potentially life-threatening complication. It presents as severe abdominal pain, abdominal swelling, vomiting, and blood clots in the legs. While only 1% of women present with severe cases, the percentage of women presenting with mild-moderate cases is rising.16, 17, 18 As discussed above, there is a risk of pre-mature birth, low birth rate, chromosomal and musculoskeletal abnormalities seen with IVF and ICSI procedures.14, 15, 17
How does a Naturopathic Doctor treat infertility?
The goals for a Naturopathic Doctor include helping the couple conceive, helping the couple maintain the pregnancy, and addressing the root cause of infertility. The fertility treatments begin with pre-conception and continue past the birth of your child. While your Naturopathic Doctor will want to address the root cause of your infertility, s/he will also want to prevent future illness that arises from the causes of your infertility. Preventative medicine focuses on creating healthy physiology for your body to prevent future ailments. As couples seeking fertility assistance usually have a support network of providers, Naturopathic doctors will work with your providers to create a comprehensive treatment plan that fits your needs.
The first visit starts with taking a thorough history for both partners. Your Naturopathic Doctor will assess the endocrine health, your adrenal and thyroid health, your hormone production, environmental influences, structural blockages, genetic defects, nutritional health, emotional health, aspects that are blocking your health and ability to conceive, and any chronic illness or inflammation that is inhibiting fertility. Your Naturopathic Doctor will order any imaging or lab testing that is deemed necessary from the visit. Some additional testing that may be indicated includes looking for anemia, assessing your Vitamin D level, and ordering a lipid panel to make sure that you have enough lipids to make hormones. Each treatment plan will vary based upon each unique history. Especially with fertility treatment, your Naturopathic Doctor will address the physiological, mental, and emotional aspects of care.
Your Naturopathic Doctor will help you address the emotional aspects and any stress that is present in your life. Lowering stress will decrease inflammation and help balance hormones. S/he will help guide you through management techniques such as breathing exercises, physical exercise, yoga, tai chi, qi gong, journaling, or counseling. Because the process of conceiving can be difficult and trying to couples, it is important to have the support that you need to manage the emotions.
Nutritionally, your Naturopathic Doctor will advise you with foods that support your body. S/he will address any foods that are adding detrimental effects to your fertility through inflammation, allergies, and environmental toxins such as pesticides. S/he will also address foods that your body needs higher amount of during a pregnancy.
Your Naturopathic Doctor may prescribe botanicals. Because botanicals have particular therapeutic effects, they are particular to unique presentations of infertility. They can be used to support the endocrine system, to provide nutrients to particular organs, to increase hormone production, and to support emotional imbalances. Botanicals can help prepare the body for conception and maintain a pregnancy.
Your Naturopathic Doctor will assess your physical structure and balance. Addressing the physical aspect of care through massage, myofascial release, structural integration, craniosacral techniques, or recommended physical activity and exercises will help the innervation and nutrition flow to your reproductive organs, and will help your body release tension and stress that can be hindering your attempts to conceive.
Your Naturopathic Doctor may recommend homeopathy or flower essences to help re-balance your overall health. These are gentle therapies that help move the body towards balance. They are a great adjunct supportive therapy to add to the care. Ask your Naturopathic Doctor what remedy is right for you.
Detoxification may be used in the pre-conception stage to prepare the body. Detoxification protocols help open any blockages in the body, help improve absorption and utilization of nutrients, help clear out physiological toxins that hinder your fertility, and help balance anxiety and stress. A good detoxification protocol will address the mental, emotional, and physical aspect of detox. By preparing the body, you are giving your body the best chance that it has at producing healthy eggs and sperm. Because every individual has a unique state of health, ask your Naturopathic Doctor about an individualize detoxification protocol.
Conclusion
Treating infertility requires a comprehensive history, assessment, and approach to care. Understanding the root cause of infertility is central for your care and the health of your future child. The health of your child begins in the pre-conception stage with you and your partner’s personal health. Naturopathic Doctors will work with any provider to form the professional support network that you need through this process. Visit your Naturopathic Doctor today to increase your fertility.
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1 Hornstein M & Kuohung W. Overview of infertility. Web March 1, 2011. http://www.uptodate.com/contents/overview-of-infertility?source=search_result&selectedTitle=1~150
2 Sarkar O, et al. Impact of inflammation on male fertility. Fronteirs in Bioscience. 2011 Jan 1;3:89-95.
3 Wasser SK, et al. Psychosocial stress as a cause of infertility. Fertility and Sterility. 1993 Mar;59(3):685-9.
4 Sandra AC, et al. Evaluation of infertility, ovulation induction, and assisted reproduction. Web March 1, 2011. http://www.endotext.org/female/female7/femaleframe7.htm
5 Baker, HWG. Clinical Management of Male Infertility. Web March 1, 2011. http://www.endotext.org/male/male7/maleframe7.htm
6 Multigner, et al. Contribution of environmental factors to the risk of male infertility. Human Reproduction. 16.8 (2001):1768-1776.
7 Main, K., Meyts, E., & Skakkebaek, N. Testicular dysgenesis syndrome: an increasingly common development disorder with environmental aspects. Human Reproduction. 16.5 (2001):972-978.
8 Agarwal, A. & Saleh, R. Oxidative stress and male infertility: from research bench to clinical practice. Journal of Andrology. 23.6 (2002):737-751.
9 The reproductive significance of human Fallopian tube cilia. Human Reproduction. 2006 Aug; 12 (4): 363-372.
10 Menge AC, Medley NE, Mangione CM, & Dietrich JW. The incidence and influences of antisperm antibodies in infertile human couples on sperm-cervcial mucus interactions and subsequent fertility. Fertility & Sterility. 1982 Oct;38(4):439-46.
11 Goldberg, JM. Comparison of intrauterine and intracervical insemination with frozen donor sperm: a meta-analysis. Fertility and Sterility. 1999 Nov;73(5):792-795.
12 Arcaini L, Bianchi S, Baglioni A, Marchini M, Tozzi L, & Fedele L. Superovulation and intrauterine insemination vs. superovulation alone in the treatment of unexplained infertility. A randomized study. Journal of Reproductive Medicine. 1996;41(8):614-8.
13 Middleton, N., et al. Procedure for intrauterine insemination. Web March 1, 2011. http://www.uptodate.com/contents/procedure-for-intrauterine-insemination?source=search_result&selectedTitle=1~150
14 Hansen, M., et al. The Risk of Major Birth Defects after Intracytoplasmic Sperm Injection and in Vitro Fertilization. New England Journal of Medicine. 2002. March;346: 725-730
15 Paulson, R. Pregnancy outcome after assisted reproductive technology. Web March 1, 2011. http://www.uptodate.com/contents/pregnancy-outcome-after-assisted-reproductive-technology?source=search_result&selectedTitle=1~150
16 Miller, K. Intracytoplasmic sperm injection. We March 1, 2011. http://www.uptodate.com/contents/intracytoplasmic-sperm-injection?source=search_result&selectedTitle=1~32
17 Balen, A. Ovarian hyperstimulation syndrome – A short report for the HFEA. Department of Reproductive Medicine. 2005. Feb. Web March 1, 2011. http://www.hfea.gov.uk/docs/OHSS_Report_from_Adam_Balen_2005(1).pdf
18 Delvigne, A. & Rozenber, S. Epidemiology and prevention of ovarian hyperstimulation syndrome (OHSS): a review. Human Reproduction Update. 8(6): 559-577.