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Infertility

An Alternative Approach to Infertility in Women

It is estimated that as many as fifteen percent of all heterosexual couples in the United States have difficulty in conceiving children. Approximately one-third of the time, this is related to issues with the man's health; one-third of the time, it is related to female health; and one-third of the time, it's a combination of the two. Infertility has been the source of much heartache, suffering and medical costs.

The foundations of the infertility workup in women are the medical history, physical examination, documentation of ovulation, endocrinologic metabolic evaluation and hysterosalpingogram. Ovulatory dysfunction is the cause of 45% of all anovulation in female infertility. Basal body temperature and ovulation test kits are the hallmark of determining ovulation. One common cause of anovulation is polycystic ovarian syndrome (PCOS), affecting 5 to 7% of reproductive-aged women. A physical exam may reveal atrophic changes, uterine fibroids, adhesions, endometriomas or other masses. A pelvic ultrasound is an important step in determining fibroids and ovarian masses. Thyroid-stimulating hormone (TSH) and prolactin levels are also fundamental aspects of the infertility workup, especially in women who are not menstruating regularly. Hypothyroidism and hyperprolactinemia are highly treatable causes of infertility. Some women will need blood testing for hormones, or maybe even a hysterosalpingogram to rule out uterine or fallopian tube abnormalities.

In men, determining infertility is a process of assessing sperm quality, motility and quantity. This is done in an andrology lab where sperm is accumulated and tested. The majority of men who are infertile suffer from a deficiency in sperm production. Infections in the male genitourinary tract can also play a role in many cases of infertility. These infections may occur in the epididymis, seminal vesicles, prostate, bladder and urethra. Chlamydia is now recognized as the most common and the most serious of the infections in the male genitourinary tract.

The purpose of the evaluation in men and women is to get a clear picture of their overall physical and emotional health, and to begin the process of creating a differential diagnosis in regards to the cause of their infertility. Determining the cause of the infertility, resolving simple and inexpensive problems, determining the impact of the woman's age on her treatment outcome, counseling, considering the impact of lifestyle on fertility and conversing about realistic expectations are all important components to preliminary reproductive counseling.

Lifestyle Influences Certain lifestyle habits can negatively impact a woman's general health and impair her fertility. Cigarette smoking can impair cervical mucus function and alter tubal ciliary transport. Decreased sex steroid production has also been noted in smokers. Smoking also increases the risk of miscarriage, perinatal mortality and low birth weight in infants. Finally, in women, smoking significantly reduces the chance of successful term pregnancy during in vitro fertilization (IVF) treatment. In men, smoking is associated with decreased sperm count and sperm motility, as well as increases in abnormal sperm.1

Caffeinated beverages have indeed been associated with decreased fertility, increased miscarriages and lower birthweights.2 More than five cups of coffee per day or more than 500 mg/day of caffeine is associated with a delayed time to conception, although we don't really understand the mechanism. One possibility is that caffeine may impair estrogen production or the metabolism of estrogens.3 Numerous caffeinated beverages including soft drinks, black tea, decaffeinated coffee, and even green tea, all contain more tannins than regular coffee. In animal experiments, tannins have reduced fertility in mice and hens.4,5

In the last few years, there has been a lot of public health information available on the importance of avoiding alcohol while pregnant, but when it comes to the influence of alcohol consumption on female fertility, mild to moderate alcohol use has not been well studied. It does seem apparent, though, that alcohol does reduce conception rates with a dose-related connection. Some research demonstrated that female alcohol intake was associated with two to three times the risk of spontaneous abortion, and alcohol intake during the week of conception increased the risk of early pregnancy loss.6 Another study showed a greater than 50% reduction in the probability of conception during a menstrual cycle in which women consumed alcohol. In this same study, caffeine consumption did not independently affect conception rates, but it may enhance the negative effect of alcohol.7

Women who are overweight are more likely to experience problems with ovulation and miscarriages. An increase in abdominal fat decreases insulin sensitivity, which is then related to ovulation dysfunction. In a woman with a body mass index (BMI) > 25, weight loss of as little as 5% can be significant in helping to normalize menses and ovulation, especially in cases of polycystic ovarian syndrome.8,9,10

Weight gain in an underweight woman is important as well. Women who are underweight have infrequent ovulation or may even lack ovulation. Eating disorders and excessive exercise can compound this problem. Overall, the preponderance of evidence suggests that a normal body weight increases the success of assisted reproductive therapies such as IVF.

Focusing on daily exercise and a whole-foods diet, free of processed foods, alcohol, and caffeine, is important to help normalize weight as well as blood sugar. However, a very recent study suggests that vigorous exercise of greater than 4 hours per week may interfere with the success of IVF and that non-exercisers may have more success with IVF intervention than exercisers.11 Moderate regular exercise is probably indicated for most individuals. In addition, in cases of exercise-related reproductive function, most of the evidence suggests that it isn't the intensity of the exercise, but the lack of adequate nutrition, specifically total calories and protein, that cause the fertility issues.12,13

In men, sperm production is inhibited or stopped if the temperature of the scrotal sac is above 96 degrees. Therefore, we must pay attention to things that influence the temperature of the scrotum. Reducing the temperature in infertile men will often render them fertile. Discontinuing the wearing of tight fitting jeans, avoiding hot tubs, and not wearing synthetic shorts while exercising are the best ways to reduce this temperature. Boxer shorts and a periodic cold shower to the scrotum will help maintain cooler scrotal temperatures.

Increasingly, environmental pollution and exposure to heavy metals, pesticides, estrogen-like substances and other chemicals are implicated in cases of infertility in men and women. Depending on the specific exposure, duration and load, different aspects of fertility can be affected. These toxic exposures may affect sperm counts, sperm formation, sperm viability, ovulation, egg viability, and hormone levels.

Enhancing Female Fertility with Nutrition and Botanicals In addition to the nutritional issues mentioned above, underweight women may need to gain weight to enhance fertility, and overweight women may need to lose weight, in the neighborhood of 10%. In women who have a short menstrual cycle, increasing soy in the diet or taking soy isoflavone supplements may increase the length of the follicular phase and delay ovulation.14 Something as simple as adding flax seeds to the diet can lengthen the luteal phase (the second half) of the cycle and increase the frequency of ovulatory menstrual cycles in women who don't ovulate regularly.15 Some simple vitamin and mineral supplementation may be keys to fertility in selected women. Vitamin E can assist with achieving and maintaining pregnancy in women with habitual miscarriages.16 A double-blind trial found that taking a multivitamin-mineral supplement increased female fertility.17 Perhaps the two most compelling supplements are arginine and PABA. Arginine supplementation at 16 grams per day has been shown to improve fertilization rates in women who had previously failed in vitro fertilization,18 and PABA supplementation of 100 mg four times daily resulted in pregnancies in 12 of 16 women with a history of infertility.19

Chaste tree berry (Vitex agnus-castus) stimulates the release of luteinizing hormone (LH) from the pituitary gland and mildly inhibits follicle-stimulating hormone (FSH). The result is an indirect ability on the part of Vitex to raise or modulate progesterone levels.20 Vitex also modulates the secretion of prolactin from the pituitary gland and, in one study, prolactin was significantly reduced, while shortened luteal phases and progesterone deficits were normalized.21

Similar to chaste tree, black cohosh (Cimicifuga racemosa) has been shown to stimulate pituitary secretion of LH and therefore lead to ovulation and subsequent production of progesterone by the corpus luteum.22,23 Black cohosh may be especially valuable for women in their forties whose FSH levels may be starting to increasing as the ovary ages.

A plant that many are not familiar with, Tribulus, has been studied as an ovarian stimulant. Women taking Tribulus every day have demonstrated the ability to normalize ovulation whereby some of the women also became pregnant.24 When using Tribulus simultaneously with an ovulation-induction drug, the results with the combined use were better than the drug by itself.25

Rhodiola may enhance fertility through several mechanisms. It has been shown to enhance thyroid function without causing hyperthyroidism in animals, and egg maturation was enhanced as well. These and other pre-clinical research led to a study that looked at the effect of treating 40 women with amenorrhea (and infertility) with Rhodiola 100 mg twice daily for two weeks. Normal menses were restored in 25 women, eleven of whom became pregnant.26,27

Numerous plants have been used in traditional herbal medicine due to their ability to regulate the tone of the uterus. In cases of infertility due to the lack of any other determined cause, these uterine tonics are thought to potentially prepare the uterus for implantation of a fertilized egg. These herbs include Dong quai (Angelica sinensis), Blue cohosh (Caulophyllum thalictroides), Crampbark (Vibernum opulus), False unicorn or helonias (Chamalerium luteum) and Squaw vine (Mitchella repens).

Dong quai can tonify a weakened uterus by improving the metabolism within the uterus28 as well as regulating hormonal control and improving the timing of the menstrual cycle.29 Blue cohosh can improve the muscular tone of a hypotonic uterus and was thought by early traditional herbalists to improve fertility. Crampbark has been used more in cases of miscarriage rather than actual infertility. It has been used traditionally both as a uterine sedative and a uterine tonic. False unicorn or helonias has been used to improve uterine tone and decrease what has been called "pelvic congestion." This herb also tends to be used more for women who have a history of miscarriage or abnormal bleeding during the pregnancy rather than true infertility. Squaw vine is a uterine tonic that increases the circulation to, and in, the uterus thereby reducing uterine congestion. It can both sedate a hypertonic uterus as well as tonify a hypotonic uterus.

Ginseng species are an important consideration in infertility due to their ability to enhance overall health, vitality, stamina and endurance. Siberian ginseng may be able to promote regulation of reproductive hormones, thereby regulating the timing of ovulation.30

Conclusion An organized and methodical approach to determine the etiology of infertility will lead one to the best therapeutic approach-whether conventional, nutritional/botanical, or a concurrent use of both. The mechanism-specific herbs are to be used in the selected underlying cause. A practice of using reliable scientific resources to look up drug/herb interactions is always prudent, although the herbs we have discussed have enjoyed a long-term history of safety when used on their own.

A treatment approach that ultimately results in a healthy baby for a wanting and able parent or parents can be one of the most satisfying experiences in providing health care.



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