INFERTILITY FROM A PHYSIOTHERAPY PERSPECTIVE

Infertility is a sensitive and challenging subject that affects many couples around the world. It influences not only physical health, but also the emotional and psychological state of those involved. Among the methods used to treat and support conception is physiotherapy. In this article we look at the link between infertility and physiotherapy, and at when this form of treatment can help women to conceive.

How does the human body work?

The human body is an open system that functions thanks to a countless number of interconnected processes. These take place at various levels – cell, tissue, organ and others. The role of these processes is to maintain homeostasis, in other words the stability of the body’s internal environment. However, homeostasis is constantly being „attacked“ by stressors:

• influences from the external environment (cold, heat,…)
• changes in the internal environment (changes in pH, changes in glucose levels, infection…)
• and, last but not least, psychosocial influences (deadlines, the death of a loved one, social factors), which throw this state of balance off.

The body is able to adapt to most of these influences and to maintain homeostasis through its main regulatory mechanisms – the nervous and hormonal systems. This is also the case for reproduction.

The most important governing component of the reproductive system is the so-called hypothalamic–pituitary–ovarian axis.

1. The hypothalamus is the lower part of the diencephalon, which secretes the hormone gonadotropin-releasing hormone (GnRH). This is transported via the bloodstream to the pituitary gland, where it stimulates the secretion of other, gonadotropic hormones (FSH and LH).

2. The pituitary gland (glandula pituitaria), an endocrine gland, produces among other hormones the above-mentioned follicle-stimulating hormone (FSH) and luteinising hormone (LH), which regulate the cyclic secretion of ovarian hormones – in other words, hormones produced by the ovaries.

The hypothalamic–pituitary–ovarian axis therefore influences fertility directly, by governing the menstrual cycle, but also indirectly, because fluctuations in these hormones affect other organ systems, which can in turn influence the reproductive system.

What are the causes of infertility in women?

When looking for the cause of infertility, we have to assume that pathology can occur at any of the levels of control mentioned above (hypothalamus, pituitary gland, gonads).

The most common cause of organic infertility in women is anovulation. This refers to irregular ovulation or to cycles with a shortened luteal phase.

Less serious causes of an imbalance in the hypothalamic–pituitary axis can include excessively intense exercise, eating disorders, excessive stress, hyperprolactinaemia and autoimmune diseases.

More serious causes include the presence of organic damage to the hypothalamic–pituitary region.

Some medicines, such as antidepressants, antipsychotics, corticosteroids and chemotherapy, are also associated with disruption of ovulation.

The length of the cycle in itself, however, is not an indicator of pathology, provided that the woman is ovulating and the luteal phase is sufficiently long (12–16 days). It is important not to fixate on the claim that ovulation occurs exactly in the middle of the cycle.

Let us give an example: imagine a woman whose cycle does not last the textbook 28 days. Let us say that ovulation occurs on day 22 of the cycle and that menstruation arrives on day 35. Such a cycle is ovulatory, the luteal phase is sufficiently long, and we can therefore consider it healthy. It follows from this that, for women who have been trying for a long time to conceive, it is essential that they know their cycle and can say with precision when ovulation occurs. There are many ways to determine ovulation; a very accurate and practical one is, for example, the sympto-thermal method, which is based on tracking the cyclic changes in cervical mucus and basal body temperature.

What should you do when you are struggling to conceive?

If you are struggling to conceive, the first step is for the woman to be examined by a gynaecologist. In addition to the basic examination, a hormonal profile should be carried out (LH, FSH, prolactin, testosterone, supplemented by thyroid hormones, blood glucose and, if necessary, further investigation of general metabolism).

If no pathology of the hypothalamic–pituitary–ovarian axis is demonstrated, we must not forget the possibility of a functional disorder of one (or more) of the reproductive organs:

• ovaries
• fallopian tubes
• uterus

At this level, the gynaecologist looks for cysts, endometriosis, polycystic ovaries, developmental anomalies of the reproductive organs (duplicity, hypoplasia, vagina duplex, vagina septa and others) and other conditions that can make it difficult for a woman to conceive or otherwise affect her health. These conditions must be ruled out, and if none of them is present, then we have to continue with differential diagnosis.

Infertility in urogynaecological physiotherapy

We address differential diagnosis through urogynaecological physiotherapy – physiotherapy in gynaecology. We assess the musculoskeletal system and focus on disorders that may affect the function of the reproductive organs and lead to so-called functional infertility.

From a musculoskeletal point of view, an important role in infertility is played by coccygeal syndrome, which is characterised by increased tension in the pelvic floor muscles. Coccygeal syndrome may be:

1. primary – meaning that it arises either locally in the pelvic floor musculature as a result of direct trauma or repetitive microtrauma (falls onto the coccyx, prolonged sitting and others)
2. secondary – it arises from inflammatory processes in the pelvis, or the source of the dysfunction is located at a distant site and the pelvic floor dysfunction is only a secondary disorder

In this syndrome, spasm of the pelvic floor muscles is almost always transmitted to the sacroiliac joints, in which a blockage develops. In the primary type of coccygeal syndrome, releasing the pelvic floor muscles also automatically releases the blockage in these joints.

In the case of secondary coccygeal syndrome, the main cause is not in the coccyx or in the pelvic floor, but is located in another part of the body, with the involvement of the pelvic floor muscles arising as a result of a chain of functional disorders. An example is one of the major chains of functional disorders, which begins in the foot, where we find a trigger point in the short flexors of the toes. This is usually followed by a blockage of the metatarsal bones, continues through the ankle and fibula, where a spasm of the biceps femoris muscle develops, and is transmitted to the ischial tuberosity. From there it continues through the strong ligaments of the pelvis and the coccygeus muscle to the coccyx, and may chain further to the other side of the body and continue upwards as far as the shoulder. To resolve such a disorder, releasing the pelvic floor muscles is not enough; the primary cause, which originates in the foot, has to be addressed.

What other problems can we deal with in urogynaecological physiotherapy – physiotherapy in gynaecology? READ MORE

How is functional infertility treated in physiotherapy?

As part of the treatment of functional infertility, women in physiotherapy often encounter mobilisations of the lumbar spine and of the sacroiliac joints (the joints between the sacrum and the pelvic bones).

The reason for this is to take advantage of the reflex relationships between the spine and the internal organs. If a dysfunction occurs in a specific spinal segment, this dysfunction will be reflected in the organ that is innervated from that segment, and vice versa.

Long-term irritation of nerve fibres by a „spinal blockage“ causes spasms to develop in the muscles around the spine and in the pelvic floor muscles. In such cases, in addition to releasing the joints of the axial skeleton, the therapy also focuses on treating the pelvic floor musculature. Releasing it leads to relaxation of the smooth muscle of the blood vessels, organs and glands on a reflex basis, thanks to the shared innervation that these structures have with the pelvic floor muscles. The result is, among other things, improved blood supply and improved quality of lymphatic drainage of the pelvic organs, and therefore also an improvement in their function.

Functional musculoskeletal disorders and infertility

There are several situations in which the musculoskeletal system can negatively affect the function of the reproductive organs. These can also occur in combination.

1. With a blockage in the area of the sacroiliac joints (the joints between the sacrum and the pelvic bones) and with hypertonia of the pelvic floor muscles, thanks to the reflex connection with the uterus (innervation from the sacral plexus), we encounter problems with painful menstruation, painful sexual intercourse and infertility due to problems with implantation. Even if implantation does take place, there is a risk of pregnancy loss.

All of this is the result of the following changes. If there is a trigger point in the pelvic floor muscles (a local increase in muscle tone with certain typical features), the reflex response is an increase in the tone of the blood vessels, which leads to poorer blood supply to the area and increased tension in the cervix of the uterus. As a result, the uterine lining is not adequately proliferated and not prepared to support implantation.

In addition to the problem of conceiving, the problem in the pelvic floor can also be recognised by clotted menstrual blood, which stays in the uterine cavity because of the increased tension of the cervix. In such cases, the uterus has to make much greater effort, in the form of contractions, in order to „expel“ the menstrual blood, which the woman experiences as pain.

Treating the reflex changes in the pelvic floor should restore the tone of the cervix and the uterine wall. The hormonal influence on the ovary–endometrium axis should also improve, and the next menstruation should not be painful and should be free of clotted blood.

If this change does not occur, the problem also lies at another level. In most such cases we also observe additional symptoms such as nausea or diarrhoea. In that case, the problem needs to be addressed in a multidisciplinary way.

2. Blockages in the area of the lumbar spine also contribute to functional sterility through reflex relationships, this time with the ovaries and the fallopian tubes. Here it is important to understand the role these organs play in fertility. The wall of the fallopian tubes is made up of ciliated epithelium, whose secretory cells produce a thin mucus, of submucosal connective tissue, and finally of smooth muscle. This muscle is relatively strong and consists of longitudinal and circular fibres, which together support peristalsis and therefore the transport of the oocyte towards the uterus. Crucially, this smooth muscle reacts to stimulation from the musculoskeletal system. In addition to these movements, the fallopian tube also performs the so-called pick-up phenomenon, a movement in which the dilated end of the tube tilts over the follicle that has just matured, bursts and releases the oocyte. With blockages of the lumbar spine, these movements/functions are negatively affected because of changes in the tone of the smooth muscle of the fallopian tube (it is important to note that the gynaecologist will not see this pathology by examining tubal patency using a contrast medium, since this is a functional, not a structural, disorder).

Infertility and psychosomatics

Psychological factors often play a role in infertility. The tension of the pelvic floor musculature depends on the state of the nervous system and on its innervation. The autonomic nervous system is under the „dominion“ of the limbic system. Excessive psychological strain combined with stress eventually leads to dysfunction of the limbic system, and this then shows up in all the systems it regulates: emotions, memory, conscious control of movement and muscle tone. When dysfunction of the limbic system leads to functional infertility, we speak of non-coccygeal syndrome. In short, this syndrome includes pelvic dysfunction and dysfunction in the axial skeleton on a psychogenic basis.

Fortunately, we can influence the autonomic nervous system in several ways. In physiotherapy we use various breathing techniques and mental training (Schultz’s autogenic training, Jacobson’s progressive relaxation).

Mechanical sterility and physiotherapy

The last type of sterility, which does not arise on a functional basis but can be influenced to a certain extent through physiotherapy, is mechanical sterility, which is caused by adhesions – the mutual sticking together of tissues.

Possible causes of adhesions include:

• repeated infections of bacterial, viral or yeast origin
• previous operations in the abdominal cavity. Even surgical procedures whose aim was, for example, to restore the patency of the fallopian tubes.
• a lack of sliding of the organs in the abdominal cavity and of movement of the organs against one another, which, if absent, leads to the formation of adhesions

For optimal movement of the organs in the abdominal cavity, the diaphragm needs to function properly; with adequate activity, it descends on inhalation, working together with the pelvic floor, which performs an identical movement. Because of the movement of the diaphragm, the organs in the abdominal cavity also move downwards. If there are already adhesions, scarring or hypertonia (for example pylorospasm) in the abdominal cavity, the diaphragm „hits“ painful signals from the visceral organs as it descends, and the body responds by changing the breathing pattern, which in turn affects the function of the pelvic floor musculature.

In physiotherapy we treat adhesions using a combination of visceral therapy, movement therapy and respiratory physiotherapy.

What does an infertility assessment at FYZIO KLINIK® look like?

If a woman who longs for a child comes to us, but despite all the examinations she and her partner have undergone no cause has been found for their lack of success so far, the following process awaits her at FYZIO KLINIK®.

At the first appointment she will undergo a detailed, comprehensive examination. We begin by taking a history, which should point us towards the suspected dysfunction we can expect to find in the musculoskeletal system. We try to determine whether this is coccygeal syndrome and, if so, whether it is the primary or the secondary form. We then continue with inspection and palpation in standing and lying positions, using our findings to confirm or refine our initial assumptions.

On the basis of these findings, we propose a treatment plan at the end of the examination, which usually combines manual techniques, exercises to do at home, physical therapy, relaxation methods and other practical recommendations.

How does the special women’s examination for suspected pelvic floor dysfunction work? VIDEO

It is important to say that one cannot expect the situation to change after a single therapy session, especially in the case of secondary coccygeal syndrome or non-coccygeal syndrome (with a psychosomatic basis), which have not arisen through direct damage to the pelvic floor but whose cause is more complex and has probably been building up over a longer period of time.

This article was prepared for you by our senior assessing physiotherapist Adriana Hlôšková, who specialises in urogynaecological physiotherapy at our clinic.

If you are interested in an examination, you can book an appointment through our FYZIO KLINIK® app or by phone via reception. CONTACT

Are you wondering:

• What do we include under women’s physiotherapy? What conditions do we address as part of this therapy?
• How is the pelvic floor connected with the rest of the body’s functioning?
• What deficits can the pelvic floor have?
• What does a healthy pelvic floor look like?
• What influences good pelvic floor condition?
• How do we assess the pelvic floor? Is a vaginal examination required?
• How do we approach the therapy?
• What other problems do we address with women as part of women’s physiotherapy?

Listen to our FYZIO KLINIK® podcast on the topic of women’s physiotherapy – urogynaecological physiotherapy.